Q?£* 


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jp'.< 


PRACTICE  OF  PHYSIC, 


COMPRISING 


MOST  OF  THE  DISEASES  NOT  TREATED  OF 


"DISEASES  OF  FEMALES," 


"DISEASES  OF  CHILDREN." 


BY  WILLIAM  P.  DEWEES,  M.  D. 

ADJUNCT    PROFESSOR    OF    MIDWIFERY    IK    THE     UNIVERSITY     OF     PENNSYLVANIA; 

MEMBER    OF    THE    AMERICAN    PHILOSOPHICAL    SOCIETY;    MEMBER    OF  THE 

PHILADELPHIA     MEDICAL     SOCIETY;     MEMBER     OF    THE    ROTAL 

MEDICAL    SOCIETY    OF    DENMARK,    &C.    &C. 


"  We  live  in  an  age  in  which  the  fear  of  debility  causes  a  prodigal  use  of 
stimulants,-  and  this  too  often,  at  the  expense  of  the  health,  and  the  life  of  the 
patient." — Broussais,  Phleg.  Chron.  Vol.  II.  p.  82. 

"  Had  I  dared  to  bleed  freely,  and  especially  by  means  of  leeches,  the  patient 
might  have  been  saved;  but  I  was  afraid  of  debility.  But,  who  is  to  blame!" — 
Tb.p.  178. 


SECOND  EDITION,  WITH  ADDITIONS  AND  IMPROVEMENTS. 


PHILADELPHIA: 
CAREY,  LEA  &  BL.ANCHARD. 

1833. 


[Entered  according  to  the  Act  of  Congress,  in  the  year  one  thousand  eight 
hundred  and  thirty-three,  by  William  P.  Dewees,  M.  D.  in  the  clerk's  office  of 
the  District  Court  of  the  Eastern  District  of  Pennsylvania.] 


SKEBRETT KIWTH  STREET, 

PHILADELPHIA. 


TO 

SAMUEL  JACKSON,  M.  1>. 

SfC.  fyc. 

THIS  WORK  IS  INSCRIBED, 

AS   A   MARK    OF  LONG-CHERISHED   ESTEEM, 

BY  HIS  SINCERE  FRIEND, 

.•  •  '  '.'  • 

WILLIAM  P.  DEWEES. 


PHILADELPHIA,  ~J 
Dec.  19,  1829.  5 


CONTENTS. 


Page. 
17 
27 
30 
31 
33 
34 
36 
37 
38 
39 
40 
42 
44 
45 
52 
54 
ib. 


General  Observations 

1.  Of  her  Qualifications  as  a  Nurse  '. 

2.  Of  the  Faithful  Administration  of  Medicine 

3.  Of  giving  Drinks  and  Nourishment      - 

4.  Of  Cleanliness  in  the  Sick  Room          .... 

5.  Of  Quiet  in  the  Sick  Room         .-        -        -        -    ''  **•' 

6.  Of  the  Ventilation  of  the  Sick  Chamber      -    >./    '/>- 

7.  Of  the  Temperature  of  the  Sick  Room         -        -    l*"i  • 

8.  Regulating  the  Warmth  of  the  Patient 

9.  The  Examination  and  Preservation  of  the  Excretions 

10.  Of  the  Patient's  sitting  up 

11.  Of  the  Making  of  the  Bed 

12.  Of  the  Proper  Using  of  the  Utensils  for  Evacuations 

13.  Of  Skill  in  Applying  and  Dressing  of  Blisters 

14.  Of  administering  Injections,  &c.  -        -        -  •••'•  >'• 

15.  Qf  the  Management  of  Convalescence         ... 

Relapse -'- 

CHAPTER  I. 

Of  Fever  in  General 65 

General  Plan  of  Cure       ,,<,-".,^,  t-,.ii 72 

A.  Of  Cool  Air  and  Drinks ib. 

B.  Of  Bleeding   •      -        -        - 75 

C.  Sweating -  77 

D.  Purging       -,."-:' 81 

E.  Of  Blisters            - 83 

a.  Of  the  Period  of  the  Disease,  or  State  of  the  Arte- 
rial System         .......  84 

b.  Of  the  Part  to  which  they  are  Applied       •        -  ib. 

c.  Of  the  Duration  of  their  Application           -        -  85 

d.  Of  the  Peculiarities  of  the  Patient  as  regards  their 
remote  effect      -        -        -        .                .        -  ib. 

F.  Tonics    -     -y^  ;•'*'-  . -_  sjfflfty  ;';"ij''      ••'    '.'•''•'.•  ib. 
SECT.  I. — Intermittent  Fever     -        -    r-';-' ''•, ;':*•       •- '•  v           .        .  87 
SECT.  II. — Remittent  Fever        .....                 ,  110 

1.  By  the  State  of  Pulse           ....                 -        -  118 

2.  By  the  Greater  or  Less  Violence  of  Symptoms    ...  120 

3.  By  the  Effects  of  Remedies '      -  ib. 

4.  By  the  Peculiarities  of  Constitution      -        -        -        -  ib. 

5.  The  Character  of  the  other  Prevailing  Diseases           -        -  ib. 
SECT.  III.— Continued  Fever      -        -        -        ...       -it      -  122 

Synochus  Form     -.----..  128 

Typhus  Form        -        -     -tv  ;.;';.;       .        -        .        -  130 

SBCT.  IV. — Typhus 143 

"  Of  the  Way  of  Attack  without  an  Accidental  Cause"         -  148 
"  Of  the  Way  of  Attack  with  an  Accidental  Cause"     V       •    '     ib. 

"Of  the  First  Degree" 149 


VI  CONTENTS. 

Page. 

"Of the  Second  Degree" 149 

"  Of  the  Third  Degree" ib. 

"Of  the  Fourth  Degree"      -        - 150 

"  Treatment  of  the  First  Degree" 151 

"Of  the  Treatment  of  the  Second  Degree"      -        -        -  ib. 

"Of  the  Treatment  of  the  Third  Degree"  152 

"  Treatment  of  the  Fourth  Degree"          ....  153 

SECT.  V.— Yellow  Fever 154 

Treatment      - 162 

CHATTER  U. 

Rubeola,  or  Measles -        -        -        -  171 

CHAPTER  IH. 

Of  Scarlatina,  or  Scarjet  Fever       t 181 

"  Belladonna  as  a  Preventive  of  Scarlet  Fever"     -        -  188 

"  Belladonna  in  Scarlatina"  ib. 

CHAPTER  IV. 

Of  Small-Pox     -                 189 

History      --                -                -        -        -        -        -  ib. 


Symptoms 

Distinct     - 

Pathology 

Treatment 

Confluent 

Prognosis 

Treatment 


Predisposing  Causes 
Exciting  Causes 
Pathology  of  Apoplexy 
Proximate  Cause 


190 
191 
192 
193 

ib. 
194 

ib. 


SECT.  I. — Modified  Small-pox,  or  Variola  Vaccina,  or  Cow-pox           -  195 

CHAPTER  V. 

Urticaria,  or  Nettle  Rash    ----.----  197 

CHAPTER  VI. 

Erysipelas 200 

1.  OfBleeding 213 

2.  OfLeeching -        -  214 

3.  Purging 215 

4.  Blisters 216 

5.  Mercurial  Ointment 217 

6.  OfBark 218 

7.  Incisions  and  Puncturing 219 

8.  External  or  Local  Applications            -        -        -        -        -  223 

CHAPTER  VII. 

Psora,  or  Itch 223 

CHAPTER  VHI. 

Diseases  of  the  Brain  and  Spinal  Marrow 226 

SECT.  I. — Phrenitis ib. 

SECT.  II.— Apoplexy           ...                 235 


240 
242 
ib. 
243 


Of  the  Treatment  of  Apoplexy  252 


CONTENTS. 


Vli 


1.  Of  the  Prophylactic  Treatment 

2.  Treatment  during  the  Paroxysm 
SECT.  III. — Paralysis  or  Palsy 

Prognostic 

Paraplegia 

Partial  Palsies 

Treatment *v>>- 

SECT.  IV. — Epilepsy 

Mode  of  Attack         -        -        -        -'•>]''• 

Diagnosis  ------ 

Remote  Causes          -        -        -        -        - 

Prognostic 

Treatment - 

SECT.  V.— Chorea  Sancti  Viti,  or  St.  Vitus'  Dance  - 

Idiopathic  Chorea 

Predisposing  Causes 

Exciting  Causes        -        -        -        - . .  --  • 

Prognostic 

Treatment 

SECT.  VI. — Tetanus -____  - 

Causes      -        -        -        -        -        -    -  - 

Exciting  Causes        -        -      '•_'-•«.  * 

Pathology 

Diagnosis          -        -        -        - 

Prognosis 

Treatment  -  -  -  -,'*•,,.,. 
SECT.  VII. — Hydrophobia 

Symptoms         -        -        -        -      '  -    .    • 

Pathology 

Treatment        -        -        -        - 


CHAPTER  IX. 

Diseases  of  the  Eyes  -        -        -        -        -        -        -- 

General  Observations -'. 

SECT.  I. — Conjunctivitis. — Inflammation  of  the  Conjunctiva 

Anatomical  Characters  of  the  Conjunctiva         -        - 

Physiological  Characters 

Pathological  Characters    -.-•!  -.  •/ ';-.    ii  -'(.;    - 

Causes 

Symptoms  of  Acute  Inflammation     - 
Symptoms  of  Chronic  Inflammation  - 

Inflammation  of  the  Conjunctiva  in  Irritable  Constitutions 

Pustular  Conjunctival  Inflammation          ••    «  .V";  *H^ ' 

Treatment        -        --..      ..  '»«  ^j,- ,;• ;:  •,- •   "        "'       ' 

1.  Blood-letting     -      c.--;j\- *.••''.$,•'•' i  /i-T^c    "        "    -    ' 

2.  Purgatives        -        -   ,     -         -        -        -        -,       . 

3.  Nauseating  Doses  of  Antimonials 

4.  Diaphoretics     -        -.     ,-        -"     • 

5.  Tonics      -        -'     .,•        *•;.•,      •        -.       - 

6.  Diet 

-7.  Blisters 

8.  Local  Applications  to  the  Eye       ,  >*  •  ,    "* 
Treatment  of  Chronic  Conjunctivitis         -        -     ,,  - 
Treatment  of  Conjunctivitis  in  New-born  Children     - 
Treatment  of  Irritable  Conjunctivitis      .  •-   ,    -  '    .- 
Treatment  of  Pustular  Conjunctivitis 

Foreign  Bodies  in  the  Eye     -      ...'•  .„  •••> ,      •  \] .~.~, 


Page. 

252 
254 
258 
262 
263 
264 
265 
268 
269 
272 

ib. 
278 
279 
282 
284 

ib. 

ib. 

ib. 
285 
287 
290 
292 
294 
298 

ib. 
300 
306 
312 
314 
315 


318 

ib. 
319 

ib. 

ib. 

ib. 
321 
326 
329 
330 

ib. 

ib. 
331 
334 

ib. 
335 

ib. 

ib. 
336 

ib. 
3391 
340 
341 

ib. 
342 


VIU  CONTENTS. 

Page. 

SECT.  II. — Sclerotitis. — Inflammation  of  the  Sclerotic*        -        -        -  343 

Anatomical  Characters  of  the  Sclerotica        ""•>'.    •-        -  ib. 

Physiological  Characters            -..-..  344 

Pathological  Characters ib. 

Causes 345 

Symptoms 349 

Diagnosis 350 

Treatment 351 

Purgatives ib. 

Diaphoretics 352 

Tonics 353 

Local  Applications        -        -        -        -        ;•'•'•        -  354 

Regimen -  355 

SXCT.  III. — Corneitis. — Inflammation  of  the  Cornea             ...  356 

Anatomical  Structure,  and  Physiological  Characters      -  ib. 

§  I.  Inflammation  of  the  Mucous  Covering  Membrane     -        -  358 

1.  Acute  Inflammation •    ib. 

Treatment #. 

2.  Chronic  Inflammation        - 360 

Treatment      ........  ;&. 

3.  Vesicular  Inflammation 361 

Treatment 362 

4.  Pustular  Inflammation       -------  ib. 

Treatment 363 

5.  Ulcerative  Inflammation             .....  364 

Treatment 365 

§  H.  Inflammation  of  the  Proper  Tissue  of  the  Cornea    -        -  ib. 


1.  Acute  Inflammation 

Treatment      - 

2.  Chronic  Inflammation 

3.  Suppurative  Inflammation 

Treatment      - 

4.  Ulcerative  Inflammation 

Treatment      - 

5.  Conical  Cornea 


ib. 
366 
368 
369 

ib. 
370 
372 
374 


6.  Encysted  Tumours  in  the  Lamellae  of  thqrCornea      -  375 

7.  Ossification  of  the  Cornea ib. 

§  III.  Inflammation  of  the  Serous  Lining  Membrane  of  the  Cornea  376 

Treatment             ' ib. 

CHAPTER  X. 

Diseases  of  the  Trachea  and  Thorax           -        -        -        -        -        -  377 

SBCT.  I.— Of  Catarrh 384 

SECT.  n. — Cynanche  Tonsillaris     •    - 396 

SBCT.  HI. — Cynancbe  Trachealis,  or  Croup 399 

Of  the  First  Stage 404 

Second  Stage,  or  that  in  which  the  Disease  is  completely  formed  405 

Third  or  Congestive  Stage                           ....  406 

Treatment  of  the  First  Stage    -                                   -        -  410 


Second  Stage 
Third  Stage 
SBCT.  IV. — Cynanche  Parotidza,  or  Mumps 
SKCT.  V. — Pertussis,  or  Hooping-cough 


412 
419 
422 
424 

Treatment         .'     ~. 432 

SBCT.  VI. — Pneumonia,  or  Peripneumonia 445 

Causes  of  Pneumonia 446 

Symptoms  of  Pneumonia,  or  Peripneumonia      -        -        -        447 


CONTENTS.  HE 

Page. 
Prognosis -        -        -        450 

Anatomical  Characters  of  Pneumonia         -        -        -  454 


Pirst  Degree,  (Obstruction) 
Second  Degree,  (Hepatization) 
Third  Degree,  (Purulent  Infiltration) 
Treatment  of  Pneumonia 

1.  Of  Blood-letting,  &c. 

2.  General  Evacuants 


455 
ib. 
ib. 

457 
ib. 

464 


3.  Blisters -  466 

4.  Alteratives ib. 

5.  Tonics       - -  ib. 

6.  Tartar  Emetic  in  Large  Doses  in  Pneumonia    -        -  467 
SKCT.  VII.— Pleurisy 478 

Of  Simple  Acute  Pleurisy 

Prognosis          .._ 488 

Acute  Hsemorrhagic  Pleurisy    -..;>.,    .    .  ..?-  ,, .        -  490 

Chronic  Pleurisy --  492 

Anatomical  Characters      -  -              -        -        -        •    •  "  •'.  •  ib. 

Signs  and  Symptoms         .-....-  493 

Of  the  Treatment  of  Pleurisy 494 

SECT.  VIII. — Phthisis  Pulmonalis,  or  Consumption     -         •        -  499 

Causes  of  Phthisis     -        - 507 

Mode  of  Development       .......  ib. 

1.  The  Miliary  Tubercles ib. 

2.  Granular  Tubercles,  or  Miliary  Granulations      -        -  508 

3.  Gray  Tuberculous  Infiltration ib. 

4.  Jelly-like  Tuberculous  Infiltration    -  ib. 
Progress    -        -        --:;'--        -        -        -  509 

5.  Encysted  Tubercles          ......  510 

Effects  of  Tubercles ib. 

Of  the  Cause  of  Tubercles 516 

'  Acute  Peripneumony"           -.-..-  517 

'  Chronic  Pneumonia"      -.---.-  ib. 

'Catarrh" 518 

'Pleurisy" ib. 

'  Of  the  Depressing  Passions  as  Causes  of  Phthisis"          -  520 

'Is  Phthisis  a  Contagious  Disease?"     •'".-.'.     ...  521 

'  Of  Hereditary  Predisposition" 523 

'Of  the  Physical  Signs  of  Tubercles"        ....  525 

Signs  of  the  Softening  of  Tubercles           ....  526 

Signs  of  the  Complete  Discharge  of  the  Tuberculous  Matter  ib. 

Symptoms  and  Progress  of  Phthisis            ....  537 

1.  Regular  Manifest  Phthisis ib. 

2.  "  Irregular  Manifest  Phthisis"           -        -        -        -  535 

3.  "  Latent  Phthisis"     -      '  -         -         -*:.  ;  -         -         -  536 

4.  "  Acute  Phthisis"     .------  ib. 

5.  "  Chronic  Phthisis" ib. 

Of  the  Treatment  of  Phthisis 537 

SECT.  IX. — Pericarditis,  or  Inflammation  of  the  Pericardium  -  -  546 

Chronic  Pericarditis 548 

Signs  of  Pericarditis  ..----,-  ib. 

Causes -  549 

Treatment 550 

SECT.  X. — Carditis     -                                   ib. 

CHAPTER  XL 

Diseases  of  the  Abdomen        "  -l:    "<•'•''     ••      -      ......      -        -  552 

2 


X  CONTENTS. 

Page. 

SECT.  I. — Peritonitis  .........  552 

Acute  Peritonitis 554 

Chronic  Peritonitis  ........  557 

SICT.  II. — Icterus,  or  Jaundice  .......  559 

Causes 560 

Symptoms -  .  563 

Diagnosis          -        -        -        -        »        *     •  «v     _        .  555 

Prognosis          ------..«  ib. 

Appearances  on  Dissection        ......  566 

Treatment 567 

SECT,  in. — Diarrhoea 570 

1.  The  Feculent  Diarrhoea              -  ib. 

a.  Directly -                -<  -      ib. 

b.  Indirectly           .......  571 

2.  Of  the  Bilious  Diarrhoea             572 

3.  Of  Mucous  Diarrhoea 574 

4.  Chylous  Diarrhoea     .......  575 

5.  Lienteric  Diarrhoea  •         ......  576 

6.  Of  the  Chronic  Form  of  Diarrhoea     -        -    .    -        -  577 
Of  the  Treatment  of  Chronic  Diarrhoea       ...  ib. 

SECT.  IV.— Dysentery 579 

Character  and  Symptoms ib. 

Diagnosis 581 

Nosological  Position  and  Pathology  ....  fi. 

Causes 582 

Is  it  Contagious?  -  -  -  -  '  -  -  -  -  583 

Terminations 584 

Conversion  into  other  Diseases          ....        -  585 

Chronic  Form             ........  ib. 

Pathology  of  Chronic  Dysentery  .....  586 

Complications  - •  ib. 

Prognosis 587 

Treatment '  -  588 

Convalescence  ........  593 

SECT.  V.— Enteritis 594 

Causes  of  Acute  Enteritis 598 

Symptoms  ----.-.--  ib. 

Treatment 602 

SECT.  VI.— Colic 605 

I.  Crapulous,  or  Flatulent  Colic 606 

Diagnosis 607 

Prognosis ib. 

Treatment ib. 

II.  Bilious  Colic ib. 

Symptoms 608 

Treatment ib. 

1.  Cathartics 609 

2.  Enemata ib. 

3.  Blood-letting -610 

4.  Warm  Bath ib. 

III.  Ileus,  or  Iliac  Passion 611 

Causes 612 

Diagnosis       -        -        -        -        -        --        -        -  613 

Prognosis ib. 

Treatment 614 

Observations           -..-----  619 

IV.  Colica  Pictonum,  or  Colic  from  Lead     ...        -  ib. 


CONTENTS. 


Diagnostic      .... 
Prognostic     .... 
Pathological  Appearances 
Treatment     .... 
SBCT.  VII. — Cystitis  .... 

Acute  Cystitis  ... 

Symptoms         .... 

Terminations     - 

Resolution         .... 

Suppuration      -        -        -        - 

Gangrene          -        -•  V-  •';.».      - 

Causes 

Treatment - '  f     - 

Regimen  -        -        -  •      -        -        -        • 

Chronic  Cystitis,  Cystirrhoea,  or  Catarrhus  Vesicse 

Symptoms         -        -    '   - 

Pathological  Changes       ... 

Treatment        -        -        -        •"  >''*-' 
STCT.  Vm.— Nephritis 

Acute  Nephritis        .... 

Causes      

Symptoms         -    *  •     '  .•••'  ~  - 

Prognosis 

Diagnosis          -        - 

Treatment     ••*.-« 

Chronic  Nephritis     -        -        -  •  ^''^ 

Symptoms         -        -        . yU  'v^ 

Diagnosis 

Prognosis 

Treatment         ...        »'n&i\ia 
S»CT.  IX. — Diabetes          -        -        -        -       i 

Definition 

Division 

Symptoms 

Proximate  Cause       .... 

Anatomical  Characters      ... 

Pathology      -   -  "  -   - 

Prognosis       -  .    -  -        -    •    - 

Treatment 

Regimen  ..... 

SBCT.  X. — Enuresis,  or  Incontinence  of  Urine    - 

Definition          ...        -  iT-,- 

Species 

Diagnosis       .  ..*'  ^  •  '  .   -        - 

Symptoms        -        -        -        - 

Causes       -        -        - 

Complete  Enuresis   .... 

Prognosis 

Incomplete  Enuresis    *     -       '-    .  *• 

Prognosis          -        -        -.-;„•- 

Nocturnal  Enuresis    ...    ..->; 

Prognosis          ..... 

Idiopathic  Enuresis  •  •    :•>,•••     •"*' 

Prognosis      \  :••  •;  •<",..l*  tT:    •':-".  :-.•;! 

Symptomatic  Enuresis       --.    •    ,    - 

Prognosis      ;..-    .  *'•-,.'.*(.   .   -       •- 

Treatment        -       -''.'- 


Page. 
622 

ib. 

ib. 
623 
626 

ib. 

ib. 
627 

ib. 
628 

ib. 
629 

ib. 
630 
631 

ib. 
632 
633 

tb. 

ib. 
634 

ib. 
635 
636 

ib. 
638 

ib. 

ib. 
639 
640 
641 
643 

ib. 

ib. 
645 
648 
649 

ib. 
650 
652 

ib. 
653 

ib. 

ib. 
654 

ib. 
655 

ib. 
656 

ib. 
657 
658 

ib. 

ib. 

ib. 

ib. 

ib. 


Xii  CONTENTS. 

«-  .  Page. 
CHAPTER  XII. 

Of  Gonorrhoea 660 

Symptoms -  661 

Diagnosis           ......                 ..  662 

Pathology          ......                 ..  663 

Treatment -   '.,'  -  ib. 

b.  Its  Acme" -  664 

c.  Its  Decline          ....                 .  665 
Gleet        - .-        -        -        -  667 

CHAPTER  XIH. 

Dropsy 668 

SECT.  I. — Hydrocephalus  Internus 673 

Dissection          .........  679 

Acute  Symptomatic  Hydrocephalus           ....  680 

Chronic  Idiopathic  Hydrocephalus 681 

Chronic  Symptomatic  Hydrocephalus        ....  683 

Of  the  Treatment 684 

1.  Bleeding -  ib. 

2.  Purging 686 

3.  Sweating 687 

4.  Topical  Applications,  and  Blistering  ib. 
SECT.  II.— Hydrothorax               689 

"  Signs  and  Symptoms" 690 

Symptomatic  Hydrothorax  ......  691 

SICT.  III.— Ascites,  or  Abdominal  Dropsy  .....  693 

Diagnosis 695 

Prognosis           .........  ib. 

Post  Mortem  Examinations  ......  696 

Treatment  of  Acute  Ascites ib. 

Regimen 697 

Purging 698 

Diuretics 699 

Purging 700 

Diuretics  -  -  -  --  --  -  -  701 

SECT.  IV. — Anasarca  --.-.v 703 

Causes 704 

(Edema  -  -  -  -  -  -  -  .  ib. 

Causes t'J. 

Treatment -  705 

CHAPTER  XIV. 

Hzmorrhagies    -                                                                                -        -  706 

Phenomena  of  Haemorrhagy 708 

Proximate  Cause        ....---.  ib. 

Remote  Causes          ........  709 

Treatment  of  Hsemorrhagy •  710 

1.  Diet 711 

2.  Bleeding -        •  ib. 

3.  Purging    - 712 

4.  Avoiding  the  Remote  Causes ib. 

SECT.  I. — Epistaxis,  or  Bleeding  from  the  Nose           ....  713 

SXCT.  H. — Haemoptysis,  or  Bleeding  from  the  Lungs  716 

Causes '    ' -"      •  717 

Phenomena       - 719 

Proximate  Cause 720 


CONTENTS.  Xiii 

Page. 

Treatment 733 

Treatment  during  the  flow  of  Blood          -        -        -  ib. 

Cathartics          -        -        -        -        .-        -        -        -  724 

Diuretics ,     -        -  ib. 

Emetics - 725 

Blisters ib. 

Partial  Warm  Bath ib. 

Cough ib. 

Diet           -        -        -     t  -        -        -        -        -        -        -  726 

SECT.  III. — Hsematemesis,  or  Vomiting  of  Blood         ....  ib. 

1.  The  Constitutional  Haematemesis      ....  727 

2.  The  Accidental  Haematemesis ib. 

3.  The  Succedaneous  Haematemesis      ....  728 

4.  The  Splanchnic  Haematemesis '-     ''«'';.        -        -  ib. 

5.  The  Critical  Hsmatemesis         «r''--'     -        -        -  729 
Proximate  Cause       -        -        -   ••  .-'•".'•;•. »        -        -        -  ib. 

,  Diagnosis 730 

Prognosis 731 

Predisposing  and  Determining  Causes       -        -        -    '    -  ib. 

Symptoms          -        -        -        -.        -        -        -        -  ''    -  ib. 

Treatment          - -  732 

SICT.  IV. — Heematuria,  or  Voiding  Bloody  Urine       ...        -  734 

Definition -  735 

Symptoms         -        -        .        .        r        .        .        .        -  ib. 

Renal  Haematuria ib. 

Haematuria  of  the  Ureter 736 

Haematuria  of  the  Bladder          ......  ib. 

Prognostic :    -  ,     -  -..-,,    -  737 

Treatment        .,,^^-j"..  ,-        .    .    •/''-    .>;,-,'.    -  738 

CHAPTER  XV. 

Rheumatism 739 

Symptoms         -        -        -'.        -        -        -        -        -  740 

Predisposing  Causes 744 

Exciting  Causes         - 745 

Proximate  Cause -         -        -  746 

Diagnosis .,*..;  747 

Prognostic  and  Metastasis          -        -        -        -        -        -  749 

Of  the  Treatment  of  Acute  Rheumatism    -        -        -        -  750 

Of  Bleeding      -:.•.*;?-        - 752 

Purging    -- 756 

Diuretics           ..---.-.-  757 

Sudorifics          -                 ib. 

Of  Opium 758 

Local  Applications 759 

Sub-acute  or  Chronic  Rheumatism    -        -        -        -        -  761 

Treatment -  763 

Cupping  and  Leeching 764 

Local  Applications   -        -        -                         -        -        -  ib. 

CHAPTER  XVI. 

Gout 767 

1.  Regular  Gout    -----  ib. 

2.  Atonic  Gout -        -  769 

3.  Retrograde,  or  Retrocedent  Gout      ....  ib. 

4.  Misplaced  Gout         -        -       f    ••  .  -  •'•••-        -        -  ib. 


XIV  CONTENTS, 

Page. 

Proximate  Cause 770 

Diagnosis           .........  {b. 

Predisposing  Causes          - ib, 

Exciting  Causes **.  771 

Prognosis  ib. 

Pathological  Changes        -        -        -        -        -        *     .  -  ib. 

Treatment » '       -  ib. 

Purging 772 

Emetics 773 

Bleeding           .........  ib. 

Opium       -,- 774 

Sudorifics 775 

Diuretics ib. 

General  Remedies ib. 

Local  Applications -  777 

Regimen  during  the  Fit 778 

Atonic  Gout 779 

Retrocedent  Gout 781 

Treatment 782 

Misplaced  Gout         - 783 

Treatment 784 

CHAPTER  XVH. 

Scrofula 785 


Prescriptions •> 791 

Glossary  explaining  the  technical  terms  used 794 

Explanation  of  the  Plate  of  the  Patterns  for  Blisters  ...  798 

Index 799 


ADVERTISEMENT. 


WOULD  it  be  either  sufficient,  or  satisfactory,  were  the  ques- 
tion asked,  "why  has  this  work  been  given  to  the  public?"  to 
merely  answer,  because  we  were  of  opinion,  that  it  was  wanted  ? 
Will  the  necessity  for  such  a  work,  insure  its  faithful,  or  best 
execution?  Certainly  it  will  not.  It  may  therefore  be  pro- 
per to  add,  that  we  have  brought  to  our  aid  in  this  compila- 
tion, (for  what  practical  work  can  pretend  to  originality,)  the 
experience  of  more  than  forty  years;  and  if  this  has  been  im- 
portant upon  the  other  occasions  on  which  we  have  troubled  the 
public,  it  must  be  no  less  useful  now,  as  it  has  been  no  less  ex- 
tensive. We  have  therefore  attempted  by  means  of  our  own  ob- 
servations, together  with  those  of  others,  as  collected  from  pretty 
constant  and  extensive  reading,  to  make  this  work  useful  and 
acceptable  to  the  student,  and  the  inexperienced  practitioner. 
Should  this  wish  ever  be  realized,  our  object  will  be  abundantly 
answered;  and  if  it  be  not,  we  must  derive  comfort  from  the 
conviction,  that  we  shall  not  have  left  the  practical  part  of  me- 
dicine, in  a  worse  condition  than  we  found  it. 

We  have  dwelt  upon  certain  points,  which  we  have  thought 
important  to  successful  practice,  with  more  than  necessary  detail 
perhaps,  to  the  experienced  physician;  but  we  are  persuaded  he 
will  forgive  this  minuteness,  when  he  reverts  to  that  period  of 
destitution  of  practical  detail  in  his  own  life,  (which  every  phy- 
sician must  have  felt  once,)  and  at  which,  he  would  so  gladly  have 
availed  himself  of  the  experience  of  another,  could  he  have  com- 
manded it.  We  now  allude  to  the  chapters,  which  treat  of  the 
general  management  of  diseases,  and  on  the  duties,  importance, 


XVI  ADVERTISEMENT. 

and  qualifications  of  the  tenders  upon  the  sick,  whether  they  be 
"  nurses"  by  profession,  by  accident,  by  necessity,  or  by  courtesy. 
We  have  attempted  to  elicit  a  more  extensive  and  strict  atten- 
tion to  the  diseases  of  the  chest,  than  has  been  generally  bestow- 
ed upon  them,  by  earnestly  recommending  the  practice  of  its 
exploration  by  the  stethoscope  and  percussion,  agreeably  to  the 
rules  laid  down  by  Laennec  in  his  inimitable,  as  well  as  invalu- 
able work  upon  this  subject.  We  would  moreover  recommend 
a  faithful  study  of  this  truly  authentic  author,  if  the  practitioner 
wish  to  arrive  at  accuracy  of  diagnosis  in  the  diseases  of  the  lungs, 
the  heart,  &c.  We  would  also  take  the  liberty  at  the  same  mo- 
ment, to  direct  the  attention  of  the  young  practitioner,  to  the 
study  of  the  works  of  Forbes,  Williams,  Andral,  Bayle,  Louis, 
Broussais,  &c.  who  have  so  rapidly  and  so  successfully  advanced 
our  knowledge  of  diagnosis,  as  well  as  the  pathology  of  the 
diseases  of  the  several  viscera  of  the  thorax,  and  other  portions 
of  the  body. 

In  treating  the  Various  diseases  which  we  have  at  present  sub- 
jected to  our  consideration,  we  have  been  particular,  whenever 
practicable,  to  dwell  upon  their  pathology  as  long  and  as  minute- 
ly as  was  consistent  with  our  present  design;  believing,  most 
firmly  ourselves,  however  incredulous  or  indifferent  others  may 
be  upon  this  point,  that  it  is  the  only  true  foundation  to  rest  prac- 
tical medicine  upon. 

The  diseases,  or  affections  of  the  eyes,  we  felt  too  important 
to  trust  their  pathology  and  mode  of  treatment,  to  our  own  ex- 
perience; we  are  therefore  indebted  to  our  friend,  Dr.  Hays,  for 
the  chapter  upon  this  subject — his  long  and  attentive  study  of 
the  subject,  together  with  his  experience  in  this  branch  of  prac- 
tical medicine,  has  amply  fitted  him  for  the  task. 

It  will  be  seen,  that  the  present  work  does  not  comprise  the 
history  and  treatment  of  every  disease  that  "flesh  is  heir  to;" 
our  reasons  for  omission  are,  first,  that  we  have  already  treated 


ADVERTISEMENT.  XVH 

of  many,  in  the  "  Diseases  of  Females,"  and  in  the  "  Diseases 
of  Children."  Second,  that  many  of  the  minor  diseases  described 
by  authors,  we  have  never  seen  ;  for  all  are  not  the  diseases  of 
our  country.  Third,  that  in  some  few  cases,  we  have  neither 
been  sufficiently  well  satisfied  with  the  investigations  of  others, 
nor  with  our  own  proper  experience  to  the  present  moment,  to 
give  them  a  place  here. 

To  conclude;  we  have  avoided  throughout  all  unnecessary  theo- 
retical discussion;  nor  have  we  in  any  instance,  attempted  to  make 
facts  square  with  preconceived  notions — or  in  other  words,  we 
have  not  attempted  to  build  a  system.'  On  the  contrary,  we  have 
carefully  studied  the  constitutional  symptoms,  and  attempted  to 
trace  their  origin  to  the  pathological  condition  of  the  parts  pri- 
marily involved,  so  far  as  they  have  yet  been  discovered.)  More- 
over, we  have  not  in  any  instance  yielded  our  assent  to  autho- 
rity, however  high,  when  it  has  been  contradicted  by  our  own 
experience;  nor  have  we  at  any  time  obtruded  our  opinions  upon 
points,  when  we  had  reason  to  believe,  that  the  observations  of 
others  had  superior  claims ;  intending  by  this,  to  make  our  own 
experience  as  available  as  we  honestly  could,  but  never  offering 
it  as  a  substitute  for  that  of  another,  unless  we  thought  we  had 
the  right  to  the  preference. 

In  this  edition,  we  have  added  several  new  chapters,  and  care- 
fully reviewed  the  old  text.  We  have  also  added  many  new 
observations  and  facts,  that  our  reading  and  experience  have  fur- 
nished us,  since  the  former  edition. 


GENERAL  OBSERVATIONS. 


1.  THE  great  light  which  the  French,  and  we  may  now  add 
the  British,  pathologists  have  shed  upon  the  nature  of  fever,  has 
enabled  us  in  a  very  remarkable  manner,  to  curtail  its  course, 
and  to  lessen  its  danger.  The  present  work  is  not  one,  in  which 
it  would  be  either  necessary  or  proper  to  discuss,  the  nature  of 
this  class  of  diseases — we  shall  therefore,  not  attempt  it.   It  will 
be  every  way  sufficient  for  our  purpose  to  state,  that  the  variety 
of  fevers  formerly  made  by  some  nosologists,  is  now  very  much 
diminished;  and  the  mode  of  treatment,  founded  upon  examina- 
tions after  death,  has  been  very  much  simplified. 

2.  Nothing  has  retarded  success  in  the  treatment  of  fevers  so 
much,  as  the  almost  endless  variety  some  nosologists  have  made; 
and  each  of  which,  agreeably  to  such  distinctions,  requiring  a 
different  mode  of  treatment.     Thus  Sauvages  gives  no  less  than 
one  hundred  and  fifty  varieties  of  fever ;  and  almost  all  the  noso- 
logists since  his  time,  though  they  have  not  gone  to  the  same 
length,   have  nevertheless  recognised  so  many,  as  to  become 
every  way  dangerous  in  practice. 

3.  In  many  instances  of  fever,  a  single  symptom  has  been 
sufficient  to  establish  a  variety,  and  a  consequent  difference  in 
treatment — thus,  we  hear  of  a  mucous  fever,  because  the  tongue 
has  happened  to  be  very  white  ;  of  a  bilious  fever,  because  it 
has  chanced  to  be  yellow;  or  a  putrid,  or  typhus  fever,  because 
this  organ  had  become  black,  dry,  or  brown,  &c.     Now,  in  all 
these  instances  the  state  of  the  stomach  was  most  probably,  may 
have  been  the  same;  differing  only  in  the  degree,  or  the  acti- 
vity of  the  inflammation,  which  was  the  original  cause  of  the 
constitutional  symptoms ;  and  which  has  these  several  states  of 
the  tongue  very  constantly,  if  not  invariably,  as  attendants.     If 
this  be  true,  and  we  think  it  cannot  well  be  disputed,  is  it  not 
worse  than  idle  to  make  distinctions,  where  there  are  no  impor- 
tant or  essential  differences?  or  to  institute  a  variety  in  treatment, 
where  one  plan,  if  it  be  the  right  one,  and  properly  pursued,  is 
every  way  sufficient  for  the  end  proposed  ! 

4.  It  appears  to  be  at  this  time  settled,  at  least  so  far  as  unani- 
mity can  prevail  upon  a  subject  not  susceptible  of  absolute  or 
rigid  demonstration,  that,  in  all  the  supposed  varieties  of  fever 
as  recognised  by  some  writers,  (but  which  by  very  many  of  the 
best  informed  practitioners  of  the  present  day,  are  looked  upon 

3 


18  GENERAL    OBSERVATIONS. 

almost  as  gratuitous,)  the  lining  membrane  of  the  stomach  is 
pretty  constantly  found  after  death  to  be  in  a  state  of  inflamma- 
tion, (more  or  less;)  and  that  all  the  constitutional  symptoms, 
or  the  phenomena  of  fever,  depend  upon  the  altered  condition  of 
this  organ ;  and  consequently,  that  all  the  remedial  means  are 
such,  and  such  only,  as  are  calculated  to  diminish  or  remove  it. 
And  further,  that  every  thing  which  has  not  this  tendency,  is 
not  only  useless,  but  is  injurious. 

5.  We  are  aware,  that  every  favourite  theory,  may  be  acted 
upon  too  exclusively  in  a  practical  sense ;  and  we  are  even  wil- 
ling to  admit,  that  the  celebrated  author  of  the  doctrine  just 
glanced  at,  pushes  his  practical  precepts  beyond,  what  we  at  this 
moment  believe,  is  warranted  by  general  experience.     Thus,  he 
confines  his  treatment  so  exclusively  to  the  reduction  of  the 
inflammation  of  the  stomach  by  leeches,  and  absolute  starvation, 
that  he  loses  sight  in  his  plan  of  cure,  of  the  necessity  of  re- 
moving the  extraneous  substances  which  almost  always  occupy 
this  organ  or  the  bowels;  and  which  cannot  fail  by  their  pre- 
sence, in  our  opinion,  to  become  irritants,  and  every  way  able 
to  perpetuate,  if  not  to  augment,  the  existing  evil. 

6.  But  on  the  other  hand  we  are  disposed  to  exercise  equal 
candour,  and  to  acknowledge,  that  much  mischief  is  constantly 
done  by  the  employment  of  means,  altogether  disproportionate 
to  the  mere  removal  of  foreign  substances  from  the  alimentary 
canal,  or  from  the  stomach  itself.     And  we  further  admit,  (but 
at  the  same  time  let  us  be  understood  that  we  reprehend  the 
mistake,  while  we  deplore  its  consequences,)  that  the  prevalent 
idea  upon  the  subject  of  clearing  the  first  passages  in  fever  is, 
that  it  requires  remedies,  active  in  proportion,  to  the  violence  of 
the  constitutional  symptoms  ;  the  .very  reverse  of  which,  is  the 
fact,  if  the  opinions  we  have  adopted  of  the  cause  and  for  the 
cure  of  fever  be  true.     Thus  in  yellow,  or  other  high  grades 
of  fever,  where  the  stomach  is  confessedly  in  a  state  of  ac- 
tive phlogosis,  the  most  drastic  remedies  are  employed,  as  tar- 
tar emetic,  calomel  and  jalap,  scammony,  gamboge,  &c.  for  their 
removal;  but  which  can  only  safely  be  treated,  by  the  mildest 
applications  to  the  stomach,  either  of  medicine  or  diet.     For  in 
the  milder  grades  of  fever,  the  stomach  will  bear  a  more  stimu- 
lating treatment,  because  the  degree  of  inflammation  is  less. 

7.  For  it  must  be  evident  that  if  the  cause  of  fever  consist 
in  inflammation  of  the  mucous  coat  of  the  stomach,  it  is  every 
way   certain,    that  emetics,    or  very   active    purgatives,  will 
not  have  a  tendency  to  remove  this  condition,  however  suc- 
cessful or  sure  they  may  be,  in  carrying  off,  from  both  stomach 
and  bowels,  the  impurities  that  may  have  occupied  them.     In 
such  cases,  no  greater  error  can  well  be  committed,  than  to  em- 


GENEBAL  OBSERVATIONS.  19 

ploy  them.  We  are  convinced  that  it  is  within  the  recollection 
of  almost  every  observing  physician,  the  surprise  he  felt  when 
the  more  active  forms  of  fever  did  not  yield  to  the  very  power- 
ful cathartics  he  employed  to  subdue  them ;  and  that  he  con- 
stantly attributed  this  want  of  success  to  the  indomitable  nature 
of  the  disease,  rather  than  to  the  ineligible  nature  of  the  means 
he  had  had  recourse  to.  He  never  dreamed  that  the  stomach 
was  in  a  state  of  high  excitement;  and  that  the  stimulating  reme- 
dies that  he  made  use  of,  were  better  calculated  to  augment  than  to 
sooth  the  condition  of  the  organ,  on  which  they  primarily  acted. 

8.  It  is  to  the  French  pathologists  chiefly,  but  especially  to 
Broussais,  and  his  friends,  that  we  are  indebted  for  the  late  im- 
portant discoveries  in  morbid  or  pathological  anatomy;  and  for 
the  great  improvement  in  the  mode  of  treating  almost  every  fe- 
brile affection  founded  upon  these  researches.     And  though  we 
admit  without  hesitation,  that  they  have  in  some  instances  run 
into  an  ultra  mode  of  treatment,  yet  we  are  in  truth  obliged  to 
acknowledge,  the  value  of  their  discoveries. 

9.  The  premises  and  deductions  of  Broussais  we  are  aware,  are 
not  universally  admitted;  but  in  this  he  shares  but  the  fate  of 
all  who  have  made  valuable  contributions  to  medical  science. 
Some  pass   over   his  suggestions  even  without  notice ;    while 
others  furiously  dispute  the  condition  of  the  organs  on  which 
they  are  based.*     The  one,  is  a  reprehensible  indifference  j  the 
other,  too  often  is  an  uncandid  examination. 

10.  Upon  this  point  Dr.  Johnson  makes  the  following  judicious 
and  emphatic  remarks.     "  If  it  be  true,  and  we  believe  it  is  as 
good  as  proved,  that  all  the  symptoms  known  to  accompany  Eu- 
ropean fevers  at  last,  also  accompany  the  disease  we  are  treat- 
ing of,  (gastro-enteritis,)  in  its  acute  form — if  it  be  true  that  in 
nine-tenths  of  these  fevers  there  are  signs  of  gastro-enteritic  in- 
flammation during  life,  and  that  unequivocal  traces  of  its  having 
existed  are  found  after  death — if  it  be  true,  that  this  connexion 
of  fever  with  the  phlogosed  state  of  the  digestive  organs  was  not 
efficiently  noticed  before  the  time  of  Broussais,  then  must  it  be 
also  true,  that  this  pathologist  has  conferred  an  incalculable  be- 
nefit on  the  healing  art,  by  calling  the  attention  of  those  that 
exercise  it,  to  this  important,   and  hitherto  neglected  coinci- 
dence.''! 

11.  The  discovery  of  the  inflamed  condition  of  the  stomach  in 
fever,  leads  to  many  highly  important  therapeutical  observancesin 

*  Indeed  we  are  certain,  that  a  number  have  reprobated  the  pathology  and 
practice  of  this  author,  without  having  ever  read  his  works,  or  at  most,  have 
become  acquainted  with  them,  only  through  the  medium  of  a  review. 

t  Med.  Chir.  Review,  April,  1828. 


20  GENERAL    OBSERVATIONS. 

the  choice,  and  in  the  administration  of  remedies,  both  as  regards 
their  qualities,  and  quantities;  and  which  will  very  emphatically 
account  for  the  many  failures  in  their  cure,  before  this  valuable 
pathological  fact  was  thoroughly  established.  It  also  points  out 
the  value  of  local  depletion,  either  by  leeches  or  by  cups;  and 
satisfactorily  accounts  for  the  frequent  success,  that  follows  the 
loss  of  a  comparatively  small  quantity  of  blood,  when  abstracted 
by  these  means,  from  the  region  of  the  stomach. 

12.  We  do  not,  however,  yield  entire  faith  to  the  French  pa- 
thology upon  the  subject  of  fever ;  namely,  that  its  seat  is  always 
in  the  stomach.     For  so  far  we  have  not  had  sufficient  proof, 
that  an  inflamed  condition  of  the  mucous  membrane  of  this  or- 
gan is  the  true  cause  of  adynamic,  or  typhus  fever.     So  far  as 
dissections  can  be  relied  on,  this  organ  has  very  often  been  found 
in  a  normal  state  in  patients  who  have  died  of  this  fever.     The 
brain,  the  liver,  the  spleen,  have  all  been   observed   to   have 
borne  marks  of  inflammation  in  the  adynamic  fevers;  and  in 
some  other  instances,  dissection  did  not  appear  to  reveal  any 
thing  that  was  conclusive  upon  this  point.     In  all  fevers  that 
may  have  marsh  miasma  for  their  remote  cause,  the  stomach 
we  believe  will  almost  always  be  found  to  be  the  seat  of  the  affec- 
tion.* 

13.  It  moreover  directs  the  choice  of  both  diet  and  drinks  in 
cases  of  fever — for  it  at  once  admonishes,  the  cautious  use  of  all; 
and  imperiously  forbids  the  employment  of  any,  that  may  be- 
long to  the  class  of  stimulants.     The  cautions  suggested  in  the 
use  of  food  and  drinks,  are  perhaps  more  extensively  valuable, 
than  those  for  the  administration  of  remedies;  for  the  use  of  the 
first  appears  to  be  more  frequently  delegated  to  the  nurse  or  at- 
tendants upon  the  sick,  than  to  form  a  part  of  the  regular,  and 
necessary  prescription  of  the  physician;  while  the  latter  forms 

*  Dr.  Hannay  says,  "  the  mucous  tissue  or  villous  coat  of  the  alimentary  ca- 
nal presented,"  (after  death  of  fever,)  "morbid  appearances  in  every  easel  have 
inspected."  (Glasgow  Medical  Journal  for  August,  1829.)  And  Dr.  Tweedie, 
(Clinical  Illustrations,  p.  6.)  says  "that  in  every  genuine  fever,  there  is 
not  one  but  several  organs,  (tissues?)  affected;  the  affection,  in  the  first  in- 
stance, at  least,  is  functional,  however  soon  this  functional  disturbance  may 
pass  into  vascular  excitement,  and  afterwards  into  inflammation."  And  he 
farther  states,  that  "  of  five  hundred  and  twenty-one  cases,  one  hundred  and 
fourteen  had  well-marked  symptoms  of  severe  cerebral  affections."  "  In  a 
large  proportion  of  the  cases,  the  condition  of  the  brain  constituted  only  part 
of  the  danger;  other  organs  being  at  the  same  time  inflamed;  for  example,  in 
thirty-six  the  head  and  chest,  in  thirty  the  head  and  belly,. and  in  fourteen  the 
head,  chest  and  abdomen,  were  simultaneously  affected.  It  thus  appears,  that 
in  one  hundred  and  eighty-four  the  brain  was  seriously  involved  in  the  febrile 
action;"  and  "that  in  thirty-seven  out  of  fifty-four,  (the  whole  number  exa- 
mined,) the  brain  showed  evident  marks  of  the  existence  of  nervous  inflamma- 
tion." p.  28. 


GENERAL    OBSERVATIONS.  21 

the  more  direct  province  of  the  medical  attendant,  and  is  usually 
conformed  to  by  those  who  have  charge  of  the  sick.* 
i»  14.  By  what  we  have  just  declared,  it  is  intended  to  convey, 
a  direct,  and  severe  censure,  to  every  practitioner  who  neglects 
to  prescribe,  with  rigorous  care,  every  article  of  food  or  drink 
his  patient  may  require.  And  at  the  same  time,  we  recommend 
to  him  to  watch  with  a  jealous  eye,  that  it  has  neither  been  al- 
tered in  quality,  nor  exceeded  in  quantity.  We  regret  that  this 
all-important  vigilance  is  not  sufficiently  often  exercised  by  the 
medical  attendant;  and  that  so  much  latitude  is  given  to  those, 
who,  from  the  very  nature  of  things,  cannot  either  comprehend 
the  character  of  the  disease,  or  be  acquainted  with  the  best  mode 
of  treating  it. 

15.  From  what  has  been  said,  it  would  appear,  that,  in  the 
cure  of  fevers,  much  will  depend  upon  the  choice,  and  the  due 
administration  of  drinks  and  food;  and,  moreover,  we  hesitate 
not  to  say,  that  all  well-regulated  experience  is  in  its  favour  of 
an  attention  to  these  points.     Thousands  have  been  called  to  an 
untimely  grave  by  the  over-officiousness  of  the  nurse,  or  the 
overweening  anxiety  of  friends;  for  both  too  often  and  too  cer- 
tainly conspire  against  the  best  interests  of  the  patient,  by  acting 
independently  of  the  suggestions  of  the  physician,  or  by  running 
counter  to  his  positive  directions. 

16.  The  office  of  "  Nurse"^  is  one  of  awful  responsibility  if 
its  duties  be  properly  considered ;  for  on  the  faithful  discharge 
of  them,  will  the  life  of  a  fellow  being  in  very  many  instances, 
almost  exclusively  depend.  How  much  intelligence,  good  sense, 
and  fidelity  are  therefore  required,  that  the  patient  may  profit 
by  her  attentions;  or  that  he  may  not  be  injured   by  her  self- 
willedness  or  neglect!  Where  there  is  a  medical  attendant,  the 
duties  of  the  nurse  are  reduced  to  two  simple,  but  highly  im- 
portant rules ;  the  observance  of  which  should  be  most  rigidly 
insisted  upon.     First,  to  do  every  thing  that  the  physician  or- 
ders to  be  done,  and  this  in  the  strict  letter  of  his  commands. 
Second,  to  do  nothing  herself,  nor  permit  any  one  else  to  do, 
that  which  he  has  not  ordered ;  for  it  is  fairly  to  be  presumed, 

*  A  physician  cannot  commit  a  greater  mistake,  than  to  leave  the  choice  of 
drinks  to  the  attendants  upon  the  sick;  this  should  be  one  of  his  unalienable 
rights,  and  one  of  his  most  positive  duties;  nor  should  he  ever  dispose  of  them. 
The  directions  for  the  drink  of  the  patient,  is  oftentimes  of  more  value  than 
the  prescription  for  medicine;  and  that  practitioner  is  highly  culpable,  who 
neglects  to  specify  both  the  kind  of  drink,  and  the  nature  of  the  aliment,  be- 
fore he  leaves,  the  sick  room.  And  we  are  sorry  to  be  obliged  to  acknowledge 
it  as  a  fact,  that  we  have  known  many  instances  where  neither  diet  nor  drinks 
were  specified  by  the  physician,  though  the  patients  were  labouring  under 
diseases  of  an  acute  form. 

f  Of  this  we  shall  speak  more  at  large  presently. 


22  GENERAL    OBSERVATIONS. 

that  the  physician  will  direct,  to  the  best  of  his  knowledge,  what* 
ever  he  may  think  is  essential  to  the  welfare  of  his  patient ; 
therefore,  for  a  nurse  to  put  her  judgment  in  opposition  to  that 
of  the  physician,  is  both  arrogant  and  dangerous. 

17.  Unfortunately  for  the  welfare  of  the  sick  it  too  often  hap- 
pens that  the  nurse  when  about  to  oppose  the  judgment,  or  dis- 
obey the  orders  of  the  physician,  enlists  on  her  side  the  imme- 
diate friends  of  the  patient,  by  unnecessarily  rousing  their  fears 
for  his  safety,  or  perhaps  still  more  reprehensibly,  by  diminish- 
ing their  confidence  in  the  skill  and  experience  of  his  physician. 
When  this  happens,  the  suffering  patient  is  left  to  the  manage- 
ment of  a  disingenuous  and  ignorant  nurse;  while  the  physician 
is  charged  with  the  entire  responsibility  of  his  recovery.   Could 
all  the  consequences  of  the  backslidings  of  nurses  be  made  to 
meet  the  public  eye,  they  would  exhibit  one  of  the  most  appalling 
pictures,  that  could  be  imagined,  where  absolute  turpitude  was 
not  concerned  in  its  production. 

18.  But  in  making  this  charge  against  this  very  important 
class  of  people,  we  mean  not  too  generally  to  impugn  their  in- 
tentions— we  are  convinced  they  act  from  an  honest,  though  a 
dreadfully  mistaken  notion,  even  in  their  greatest  deviations. 
For  it  unfortunately  happens  that  most  nurses  have  their  own 
notions  of  the  nature  and  cure  of  every  disease  they  may  be 
called  upon  to  watch;  and  but  too  often  act  upon  their  own  the- 
ories, to  the  subversion  of  the  plans  of  the  physician;  and  not 
unfrequently,  to  the  destruction  of  the  patient. 

19.  Now,  can  it  be  for  a  moment  supposed,  that  an  ignorant, 
uneducated  woman,  (be  her  experience  what  it  may,)  shall  be  as 
well  qualified  to  judge  of  the  condition  of  a  patient,  as  the  man 
who  has  devoted  the  better  portion  of  his  life  to  the  investiga- 
tion of  diseases?     This,  we  are  persuaded,  will  be  answered  by 
every  thinking  being,  in  the  negative;  yet,  is  there  a  physician 
living,  who  has  not  seen  many  instances,  where  the  opinion  of  a 
nurse  was  preferred  to  his!  As  a  mere  matter  of  calculation, and 
to  which  every  school-boy  is  altogether  competent,  it  will  be 
found,  that  in  no  instance  can  the  judgment  of  the  nurse  be  equal 
to  that  of  a  well-instructed  practitioner,  of  even  moderate  prac- 
tice.  For  a  nurse  cannot  for  the  most  part,  attend  but  to  a  single 
patient  at  a  time;  and  the  whole  that  may  fall  under  her  charge, 
amount  to  a  very  few;  consequently  her  observations  must  from 
the  very  nature  of  things  be  very  limited;  while  the  physician, 
in  the  same  period,  may  have  seen  hundreds;  and  of  the  condi- 
tion of  which,  from  education,  habits  of  thinking,  and  talent  for 
observation,  he  is  infinitely  better  qualified  to  decide  upon  the 
nature  of  the  disease,  and  its  mode  of  treatment. 

20.  Though  the  evils  of  which  the  physician  has  so  much 


GENERAL    OBSERVATIONS.  23 

cause  to  complain  arise  almost  always  from  the  direct  agency 
of  the  nurse,  yet  they  are  less  to  blame  in  other  instances  than 
the  immediate  relations  and  friends  of  the  patient.  For  did  not 
the  latter  consent  to  become  faithless  to  their  duty  ;  a  duty  ren- 
dered sacred  by  every  tie,  and  by  every  law,  the  nurse  could 
not,  perhaps  would  dare  not,  act  contrary  to  the  most  abso- 
lute, and  well-defined  directions,  of  the  physician.  It  is  quite 
time  that  this  grievance  should  be  redressed — it  is  the  bounden 
duty  of  every  individual  in  society  to  aid  in  this  all-important 
change;  nor  is  the  remedy  difficult  to  find — for  it  consists  sim- 
ply, in  each  individual  determining  to  become  faithful  to  his  own 
interests,  by  disregarding  the  crude  opinions  of  an  ill-instructed 
nurse. 

21.  The  injuries  which  the  sick  receive  from  improper  nurs- 
ing, are  not  always  chargeable,  as  we  have  just  hinted,  to  the 
nurse,  properly  so  called — the  near  friends  of  the  patient,  from 
whom  we  have  a  right  to  expect  better  things,  are  equally,  and 
sometimes  solely  culpable;  for  they,  like  the  nurse,  have  their  own 
notions  to  support;  and  unfortunately  they  do  support  them;  and 
this,  too  often,  at  the  sacrifice  of  the  patient. 

22.  There  are  two  consequences  always  dreaded  by  the  ill- 
instructed,  in  almost  every  case  of  acute  disease — namely,  de- 
bility, and  typhus.     These  phantoms,  haunt  the  imagination 
with  such  frightful  constancy,  as  to  dethrone  reason  and  to  an- 
nihilate judgment.     They  are  the  dreaded,  and  constantly-rung 
tocsins  in  the  ears  of  the  physician;  and  unfortunately,  if  he  be 
not  a  man  of  marked  moral  courage,  and  have  not  proper  confi- 
dence in  himself,  he  becomes  so  appalled  and  overpowered  by 
this  din,  as  to  yield  up  his  judgment;  and  this,  to  the  destruc- 
tion perhaps  of  the  life  entrusted  to  his  care. 

23.  The  friends,  with  a  view  to  destroy  these  imaginary 
evils,    (debility  and  typhus,)  insist  upon  the  use  of  improper 
remedies,  but  more  especially  upon  improper  diet,  and  drinks; 
which,    if  yielded   to,  is  sure  to  injure,  if  not  to  destroy  the 
patient.     Inflammation,    and   its   consequences,   must,    in   the 
opinion  of  these  alarmists,  be  suffered  to  run  on,  or  to  increase, 
because,  the  remedies  most  suitable  to  relieve  them,  are  suppos- 
ed only  calculated  to  increase  the  dreaded  debility,  or  to  bring 
on  horrid  typhus.  Hence,  the  destructive  administration  of  bark, 
volatile  alkali,  wine,  &c.  or  the  almost  equally  destructive  use 
of  broths,  chicken  water,  or  animal  food,  in  one  form  or  other, 
during  the  continuance  of  fever.     And  we  may  here  declare, 
once  for  all,  that  it  is  our  most  solemn  and  deliberate  opinion, 
that  the  attempt  to  guard  against  this  supposed  debility,  and  this 
dreaded  typhus,  has  caused  more  deaths,  than  the  unrestrained 
Plague,  or  the  fatal  yellow  fever. 


24  GENERAL    OBSERVATIONS. 

24.  We  have  dwelt  upon  this  subject  perhaps,  beyond  the  pa- 
tience of  the  reader ;  but  certainly  not  longer  than  the  subject 
demands,  or  its  importance  merits;  and  especially  by  those,  for 
whose  more  immediate  use,  this  work  was  undertaken.     The 
directions  for  the  management  of  the  various  diseases,  must  be 
regarded  as  the  opinions  of  the  physician,  by  those  not  connect- 
ed with  the  profession ;  and  consequently,  general  rules,  must 
not  be  deviated  from  without  a  great  or  a  well-weighed  cause,  if 
success  is  to  follow  the  plans  of  treatment  laid  down  in  these 
pages.  For  due  consideration  has  been  bestowed  on  each  portion  of 
the  work ;  and  every  direction  given  for  the  management  of 
the  various  diseases  treated  of,  is  the  result  of  the  experience 
of  the  most  approved  authorities,  aided  by  that  of  the  author. 

25.  We  cannot,  however,  dismiss  this  subject  yet;  we  feel  it 
important,  again  to  recur  to  the  vulgar  errors  on  the  hackneyed 
points  of  debility,  and  typhus. 

26.  Weakness,  or  debility,  is  the  necessary  consequence  of 
disease,  whether  it  be  suffered  to  run  its  course  without  inter- 
ference, or  has  been  treated  agreeably  to  the  rules  of  art.     The 
patient  and  the  disease,  therefore,  must  be  looked  upon  as  a 
unit;*  and  consequently,  whatever  abates  the  one,  must  necessa- 
rily diminish  the  other;  and  in  most  instances  of  acute,  and  con- 
tinued disease,  there  is  no  removing  the  one,  but  at  the  expense 
of  the  other.    This  fact  should  constantly  be  borne  in  mind;  be- 
cause, as  a  great  practical  truth,  it  may  tend  to  diminish  the  ap- 
prehensions just  named,  as  well  as  give  the  best  possible  chance 
for  the  patient's  recovery. 

27.  It  should  also  be  recollected,  that  debility  is  not  disease; 
it  is  only  one  of  its  insuperable  attendants ;  and  is  never,  or  but 
very  rarely,  of  itself,  the  cause  of  death;  for  we  may  from  long 
experience  very  safely  say,  where  one  dies  from  pure  debility, 
an  hundred  perish  from  over-stimulation,  or  from  the  remedies 
purporting  to  counteract  weakness. 

28.  The  proper  plan  then  to  remove  debility,  must  be  to  cure 
the  disease;  but  the  contrary  course  is  almost  constantly  pur- 
sued; the  consequences,  we  shall  not  repeat.     Let 'us  for  a  mo- 
ment look  at  the  means  usually  employed  to  support  strength, 
or  to  prevent  typhus.     They  will  be  found  to  consist  of  all  the 
more  powerful  stimulants  in  our  possession;  and  whether  they 
range  under  the  head  of  medicines,  or  be  regarded  as  articles  of 
diet,  they  are  for  the  most  part,  equally  improper.     Under  the 
former,  the  bark,  volatile  alkali,  opium,  aether,  phosphorus,  and 
all  the  bitters,  may  be  classed ;  and  under  the  latter,  brandy, 
wine,  porter,  ale,  alcohol,  animal  food,  broths,  and  jellies,  may 
be  ranked 

*  Dr.  Rush. 


GENERAL    OBSERVATIONS.  25 

29.  It  is  a  fact  generally  admitted,  that,  the  remedy  which  is 
not  calculated  to  diminish  or  overcome  a  disease,  is  almost  sure 
to  increase  it — now,  fever  for  the  most  part  has  for  its  cause,  a 
local  inflammation  ;  and  that  inflammation  is  seated  in  one  of  the 
most  important  organs  of  the  body;  namely,  the  stomach;  if  this 
be  admitted,  and  admitted  it  is,  by  many  of  the  most  enlightened 
of  the  profession,  will  not  the  common  sense  of  mankind  revolt  at 
the  idea,  that  this  formidable  condition  of  the  system,  is  to  be 
overcome  by  means  like  those  just  enumerated? 

30.  Let  it  not,  however,  be  imagined,  that  our  treatment  of 
acute  diseases,  excludes  all  nourishment,  or  every  stimulant  from 
its  plan.     On  the  contrary,  it  will  be  seen,  that  both  one  and  the 
other  are  employed;  and  that  we  only  insist  upon  proper  selec- 
tion, quantities,  and  periods  of  exhibition.     Our  nourishments 
will  be  derived  almost  exclusively  from  vegetable  substances; 
and  our  stimulants,  will  be  mainly  confined  to  external  applica- 
tion.    We  must  attempt  to  remove  another  vulgar  error ;  one 
which  has  unfortunately  an  application  as  extensive,  as  it  is  mis- 
taken, and  mischievous;  namely,  that  all  stimulants,  (whether 
durable  or  diffusible,)  are  tonic  and  bracing,  and   consequently 
calculated  to  prevent,  or  remove  the  monster  debility,  and  thus 
secure  the  patient  against  the  other  dreaded  consequence,  typhus. 

31.  Hence,  alcohol,  in  the  form  of  brandy,  wine,  &c.,  is  by 
too  many,  emphatically  called,  strengthening — and  hence,  its 
almost  universal  employment,  in  the  decline,  and  in  some  in- 
stances, at  the  very  acm6  of  the  disease,  by  those,  whose  imagi- 
nations teem  with  the  fear  of  debility,  and  of  typus;  and  hence, 
as  we  have  too  often  witnessed,  the  too  certain  production  of  the 
very  conditions,  so  much  held  in  dread. 

32.  This  last  assertion  is  not  a  creature  of  the  imagination;  it 
is  too  truly  founded  in  fact;  and  we  pledge  our  best  hopes  upon 
its  truth.     Nay  further ;  we  have  many  times  seen  a  simple  in- 
termittent with  well-marked  intervals,  converted  into  a  highly 
dangerous  remittent;  and  have  more  than  once  witnessed  the 
latter,  goaded  into,  what  is  usually  termed  typhus,  by  the  too 
early  or  too  powerful  application,  of  stimuli.     And  we  now  in- 
sist once  for  all,  that  debility  never  was,  nor  never  can  be  re- 
moved by  diffusible  stimuli,  alone.    As  well  might  the  unmerci- 
ful rider  expect  the  renovation  of  the  flagging  strength  of  his 
sinking  horse  by  the  application  of  his  spurs,  as  for  us  to  attempt 
the  restoration  of  strength  to  the  human  body,  by  the  mere  ex- 
hibition of  alcohol,  in  any  shape  or  form,  whatever.     Let  it  be 
remembered,  that  under  the  best  circumstances  it  is  rarely  use- 
ful ;  and  to  be  so,  requires,  that  its  exhibition  should  be  most 
nicely  timed,  as  well  as  regulated  by  the  soundest  judgment. 
Let  it  also  be  borne  in  mind,  that  where  it  is  once  fortunately 

4 


26  GENERAL    OBSERVATIONS. 

employed,  it  is  an  hundred  times  improperly  applied.  Indeed, 
the  same  may  be  said  of  some  other  substances,  though  they  are 
usually  termed  very  innocent;  namely,  the  solution  of  animal 
jellies,  in  the  form  of  broths,  as  beef  tea,  chicken  water,  &c. 

33.  We  feel  it  highly  proper  to  be   more  explicit  upon  the 
subject  of  animal  jellies;  and  in  so  many  words  declare,  we  know 
of  no  period  in  the  continuance  of  any  acute  disease  or  fever, 
where  they  are  admissible;  or  rather,  where  they  will   not  do 
harm.     We  are  truly  of  opinion,  that   "chicken  water,"  that 
simple,  innocent  substance,  as  it  is  usually  called,  has  done 
more  mischief  in  acute  diseases,  than  even  the  ill-judged  use  of 
the  lancet,  or  mercury  too  freely  urged.     For  the   "chicken 
water"  is  ever}7  day,  and  very  often  in  the  same  day,  producing 
its  mischief;  while  that  from  bleeding  and  mercury  under  the 
circumstances  stated,  is  of  comparatively  rare  occurrence — yet 
so  common  and  inveterate  are  the  prejudices  in  its  favour,  that 
we  fear  we  shall  too  rarely  be  believed,  and  too  seldom  aided  in 
its  proscription. 

34.  We  are  seriously  of  opinion,  that  a  majority  of  the  re- 
lapses in  acute  diseases,  is  owing  to  the  injudicious  employment  of 
the  "  innocent  chicken  water."  We  well  remember  an  instance, 
where  only  three  table-spoonfuls  of  this  animal  solution,  created 
so  much  fever,  and  so  severe  a  renewal  of  the  pain  of  pleurisy, 
that  seven  bleedings  were  required  to  subdue  them  ;  though  at 
the  moment  of  its  exhibition,  the  friends  of  the  patient,  and  her 
physician,  thought  her  in  a  state  of  convalescence. 

35.  It  is  in  the  unadvised  and  injudicious  use  of  animal  sub- 
stances, either  entire,  or  in  solution,  that  nurses  most  frequently 
effect  the  mischief  complained  of  above.     They  cannot  compre- 
hend, how  a  small  piece  of  meat,  a  little  broth,  or  a  few  spoon- 
fuls of  chicken  water,  shall  do  harm  to  a  patient  who  is  labouring 
under  fever,  and  who  is  confessedly,  very  weak;  and  though  they 
quickly   after  its  exhibition  witness   an   aggravation   of  every 
symptom,  they  never  charge  the  mischief  to  the  improper  food  ; 
and  therefore  they  do  not  profit,  even  by  experience. 

36.  In  the  same  way,  and  with  similar  results,  do  they  venture 
upon    "  seasoning   the    victuals  with  a  little  dash  of  wine  or 
brandy,"  contrary  to  the  most  positive  prohibitions  of  the  phy- 
sician.    Is  it  then  surprising,  that  fever  should  have  so  many 
victims,  when  the  force  of  the  disease  is  aided  by  the  covert 
conspiracies  of  the  attendants  upon  the  sick !     It  were  devoutly 
to  be  wished,  that  the  nurse  in  the  exercise  of  her  duties,  would 
constantly   appeal  to  her  conscience;  for  did  she,  she  would 
most  probably  pause,  and  possibly  cease  to  act,  upon  her  own 
responsibility. 

37.  Hitherto,  we  have  only  adverted  to  the  errors  committed 


GENERAL    OBSERVATIONS.  27 

by  the  attendants  upon  the  sick,  and  exposed  a  few  of  the  more 
prominent  sources  from  which  they  arise.  We  shall  now  lay 
down  a  few  rules  for  the  government  of  the  sick  room,  believ- 
ing that  a  work  strictly  practical  like  the  present,  would  be  very 
defective  without  them. 

38.  It  is  universally  admitted,  that  "  good  nursing  is  half  the 
cure;"  yet  there  are  but  few  who  understand,  in  what  this  really 
important  art,  consists.     And  were  we  to  describe  it  by  nega- 
tives we  should  almost  be  tempted  to  say,  that  it  consists,  in 
almost  every  thing,  but  that  which  is  absolutely  done.     But  as 
this  brevity  would  not  serve  the  purposes  we  aim  at,  we  shall 
descend  to  some  general  principles,  and  the  rules  resulting  from 
them. 

39.  In  the  first  place,  the  physician  has  to  acknowledge,  that 
his  attentions  upon  the  sick  would  be  altogether  unavailing, 
were  his  directions  not  obeyed  by  the  nurse,  and  this,  in  the 
most  faithful  manner;  the  rule  to  be  followed  by  the  nurse  must 
therefore  be  obvious;  namely,  to  follow  them,  most  implicitly. 
But  the  duties  of  the  nurse  are  various  as  well  as  important;  and 
consist  of  proper  qualifications  for  the  office ;  the  faithful  admi- 
nistration of  medicines;  the  giving  of  drinks  and  nourishment; 
attention  to  cleanliness;  keeping  the  room  quiet;  procuring  its 
proper  ventilation  ;  preserving  a  proper  temperature  of  the  air 
of  the  room;  regulating  the  warmth  of  the  patient;  the  examina- 
tion and  preservation  of  his  excretions ;  her  management  of  his 
sitting  up;  making  of  the  bed  ;  the  proper  use  of  the  utensils  for 
the  evacuations ;  the  mode  of  giving  him  drinks;  the  applica- 
tion and  dressing  of  blisters;   the  administration  of  enemataj 
and  management  of  the  patient  during  convalescence. 

1.    Of  her  Qualifications  as  a  Nurse. 

40.  In  every  department  of  life,  however  humble,  or  however 
dignified,  it  will  be  found,  that  certain  qualities  are  essential  to 
the  best  fulfilment  of  the  duties  belonging  to  each.     To  the  one 
we  are  now  considering,  too  little  consequence  has  hitherto  at- 
tached; it  has  been  imagined,  that  any  female  was  competent  to 
this  end,  provided  she  had  no  absolute  or  physical  incompatibi- 
lity ;  than  which,  no  greater  error  can  well  exist. 

41.  Both  mental  and  physical  powers  are  essential  to  a  good 
nurse ;  without  the  first,  she  will  lack  a  most  important  quality, 
namely,  judgment;  for  without  this  she  would  not  profit  even  by- 
experience.     She  may  possibly  be  competent  to  follow  a  parti- 
cular, or  a  strictly  marked  out  routine  ;  but  will  rarely  be  able 
to  generalize  her  duties,  so  as  to  make  them  available  to  the  best 
interests  of  her  patient.    She  could  not  be  trusted  with  safety  to 


28  GENERAL    OBSERVATIONS. 

execute  a  general  order,  by  which  remedies  are  to  be  persevered 
in,  or  withheld,  agreeably  to  the  varying  condition  of  the  disease. 
She  cannot  make  herself  mistress  of  the  import  of  symptoms ;  or 
become  familiar  with  the  several  states  of  the  pulse.  In  a  word, 
she  would  want  the  happy  faculty  of  combination,  so  often,  all- 
important  to  the  sick.  The  reverse  of  all  this  may  rationally  be 
expected  from  one  who  has  cultivated,  to  a  certain  extent,  a  na- 
turally good  understanding,  and  who  has  made  herself  mistress 
of  her  duties. 

42.  She  should  be  a  woman  of  close  observation,  and  of  strict 
veracity ;  the  first  will  enable  her  to  detail  to  the  medical  attend- 
ant the  various  changes  of  the  disease ;  or  it  will  instruct  her  in 
the  application,  or  the  withholding  of  the  different  remedies,  as 
may  be  pointed  out  by  the  physician,  or  by  the  books  of  instruc- 
tion she  may  be  obliged  to  follow.   The  second  is  eminently  re- 
quired, that  no  exaggerated  statement,  nor  suppressed  truth,  may 
mislead  the  judgment  of  the  medical  attendant  in  forming  his 
plan  of  treatment. 

43.  She  should  possess  an  ample  share  of  both  moral  and  ani- 
mal courage,  that  no  condition  of  the  patient  may  make  her  flee 
the  bed  side  of  her  patient,  or  permit  him  to  rise  at  an  improper 
moment,  or  to  commit  acts  of  violence  upon  himself;  and  that 
she  may  be  able  to  withstand  his  solicitation  for  things  that  are 
improper,  or  that  have  been  forbidden.  Yet  must  she  be  all  gen- 
tleness in  manner;  or  soothing,  or  commanding  in  tone,  as  cir- 
cumstances may  require.     She  should  possess  feeling;  that  she 
may  the  more  readily  be  prompted  to  her  duties ;  but  she  must 
not  be  so  far  led  astray  by  it  as  to  betray  alarm,  where  there  is 
even  just  cause  for  it ;  but  she  should  especially  guard  against  it, 
when  there  is  none. 

44.  She  should  possess  moral  honesty,  that  she  may  com- 
pletely understand  her  situation  as  regards  those,  whose  orders, 
from  the  nature  of  her  office,  she  has  voluntarily  bound  herself 
to  obey.     Her  duty  consists  in  passive  obedience;  and  when 
she  refuses  this,  she  breaks  a  contract ;  and  if  she  follow  her 
own  promptings  in  the  management  of  the  patient,  she  betrays 
a  trust,  by  which,  she  may  counteract  the  best  devised  plan  of 
treatment ;  or  may  heedlessly  destroy  a  fellow  being,  by  a  de- 
parture from  her  prescribed  duty. 

45.  It  is  at  once  obvious  she  should  possess  sufficient  physical 
powers,  that  she  may  not  sink  under  the  weight  of  her  duties; 
and  that  she  may  be  able  to  give  every  necessary  aid  to  the  pa- 
tient, where  his  own  strength  is  incompetent ;  where  it  should 
not   be   exerted,    or   where   it   would   be   exhausted,  were  it 
employed.     But,  with  a  view  to  maintain  her  strength,  she 
should  be  supported  by  a  proper  diet,  and  such  occasional  rest, 


GENERAL    OBSERVATIONS.  29 

as  the  exigences  of  the  case  may  permit.  The  comfort  of  the 
patient  is  very  often  dependent  upon  the  physical  powers  of 
the  nurse;  the  weariness  arising  from  a  position  too  long  con- 
tinued ;  or  the  restlessness  consequent  upon  sickness,  can  only  at 
times  be  relieved  by  changes  of  posture ;  and  for  these  changes, 
he  must  be  dependent  upon  the  physical  powers  of  the  nurse. 

46.  To  effect  these  changes,  requires,  on  the  part  of  the  attend- 
ant, not  only  the  physical  powers  insisted  upon  as  essential  to  this 
character,  but  also  an  entire  willingness  to  perform  these  duties 
in  the  best  manner,  and  as  often  as  may  be  demanded;  amia- 
bility,  and   goodness  of  temper,  are  therefore  also  required. 
Every  body  that  has  been  prostrated  upon  the  bed  of  sickness, 
knows  full  well  how  eminently  it  is  in  the  power  of  the  nurse, 
to  render  it  more  supportable,  by  a  kind,  willing,  and  amiable 
deportment.     And  the  obligations  which  an  affectionate  carriage 
imposes  upon  the  sick,  is  ever  after  acknowledged  by  a  grateful 
recollection  of  it.     So  important  is  mild  and  attentive  conduct  in 
a  nurse  sometimes,  that  it  contributes  largely  towards  recovery. 
And  so  decidedly  injurious  is  a  contrary  conduct,  in  some  in- 
stances, that  it  is  sure  to  render  sufferings  more  intense,  if  not, 
to  augment  danger;  while  in  others,  it  has  too  certainly  destroyed. 

47.  Much  depends  upon  the  mode  of  exhibition,  that  medi- 
cines may  be  faithfully  swallowed;  or  that  they  be  not  constantly 
rejected.     A  cheerful,  persuasive  manner  on  the  part  of  the 
nurse,  will  often  conquer  a  disgust  that  is  almost  consequent  upon 
remedies  being  presented;  and  they  are  almost  sure  to  be  taken, 
even  by  children,  if  she  administer  them  with  delicacy,  and 
choses  the  proper  moment  for  their  exhibition.  She  should  there- 
fore possess  so  much  prudence,  as  not  to  excite  aversion,  by  talk- 
ing of  their  ungrateful  taste,  or  their  forbidding  effects;  and  she 
should  have  so  much  tact,  as  to  seize  upon  the  instant  at  which 
they  will  be  taken.  And  upon  the  importance  of  the  regular  ad- 
ministration of  medicine,  every  body  is  agreed. 

48.  Nature  appears  to  have  endowed  the  female  in  an  especial 
manner,  with  a  capacity  to  support  fatigue,  and  to  endure  priva- 
tions; hence,  their  peculiar  fitness  for  the  duties  of  nurses.  And 
should  one  not  possess  these  qualities,  she  is  altogether  disquali- 
fied for  the  important  office  of  a  "good  nurse"     The  sick,  re- 
quire the  utmost  vigilance  of  the  nurse;  she  should  therefore, 
not  be  a  heavy  sleeper;  nor  even  be  unusually  prone  to  sleep, 
lest  he  may  suffer  from  the  want  of  her  attentions.     This  is  par- 
ticularly the  case,  where  the  patient  is  much  exhausted,  for  some- 
times he  is  unable  from  weakness  to  rouse  her,  when  he  may 
much  require  her  care.* 

*  Some  nurses  not  only  sleep  profoundly,  but  also  snore  loudly;  serious,  and 
double  disadvantages.     We  visited  a  gentleman  who  had  the  misfortune  to  be 


30  GENERAL    OBSERVATIONS. 

49.  But  as  no  one  can  endure  the  loss,  of  but  a  certain  portion 
of  sleep,  the  nurse  should  be  indulged  to  take  a  nap  during  the 
day,  at  a  time  she  can  be  best  spared  from  the  sick  room,  that 
she  may  be  able  to  resume  her  watch  at  night.     To  more  effec- 
tually insure  vigilance,  the  nurse  should  abstain  from  every  spe- 
cies of  liquor,  unless  it  may  be  a  small  quantity  occasionally,  if 
she  be  really  exhausted  by  long  watching,  or  over-exertion;  so- 
briety is  a  sine  qua  non  to  the  nurse. 

50.  Cleanliness  in  habits,  is  of  immense  consequence  to  a  nurse; 
she  should  pay  scrupulous  attention  to  her  clothes  being  frequent- 
ly changed,  and  always  clean.     Her  hands  should  be  frequently 
washed;  and  she  should  not  use  tobacco  in  any  shape  whatever; 
if  she  snuff,  her  fingers,  by  which  she  is  to  prepare  the  nourish- 
ment of  the  patient,  will  be  always  begrimed  with  this  disgust- 
ing article;  if  she  chew,  or  smoke,  her  breath  will  be  highly  of- 
fensive.    And,  indeed,  it  would  always  be  a  good  practice  for 
her  to  carefully  rince  her  mouth  after  each  meal;  as  the  stomach 
of  the  patient  is  often  made  to  revolt,  from  the  impression  of  dis- 
agreeable odours,  upon  the  nose. 

51.  Let  it  be  borne  in  mind  however,  that  too  much  duty 
should  not  be  imposed  upon  the  nurse;  for  if  this  be  done,  she 
may  fail  at  a  moment,  when  of  all  others,  her  services  may  be 
required.     To  prevent  such  accident,  her  strength  of  constitu- 
tion should  be  consulted;  that  no  more  may  be  put  upon  it,  than 
it  is  well  able  to  bear.   In  cases  of  long-protracted  illness,  there- 
fore, other  assistance  should  be  added,  so  as  to  afford  her  an  op- 
portunity for  proper  rest;  or  if  much  exhausted,  for  entire  reno- 
vation. This,  in  many  instances,  is  a  matter  of  much  consequence 
to  the  patient,  for  the  one  who  has  been  long  about  his  person 
becomes  familiar  with  his  habits,  as  well  as  with  those  of  his  dis- 
ease. 

2.   Of  the  Faithful  Administration  of  Medicine. 

52.  If  there  be  any  power  in  medicine  over  disease,  it  must 
be  owing  to  its  proper  selection,  and  its  well-timed  exhibition. 
It  is  left  for  the  physician  to  make  the  choice  of  the  remedy;  but 
it  depends  too  often  upon  the  nurse,  whether  it  be  efficacious  or 
otherwise.  It  is  in  vain  that  remedies  are  procured,  or  by  what- 

attended  by  one  of  these  unmusical  nurses;  on  one  occasion  upon  my  inquiring 

of  her  how  Mr. had  slept,  she  answered  "delightfully;  he  did  not  wake 

once  the  whole  night."  The  gentleman  on  the  other  hand  assured  me,  in  a 
faint  and  exhausted  voice,  that  he  had  not  closed  his  eyes  during  the  night; 
nor  could  he,  for  the  loud  snoring  of  the  nurse.  Nor  could  he  rouse  her,  by 
any  effort  his  feeble  powers  permitted  him  to  make;  in  consequence  of  which, 
lie  suffered  much  for  drink,  &c.  during  the  whole  night. 


GENERAL    OBSERVATIONS.  31 

ever  experience,  or  talent  they  may  be  prescribed,  if  they  be  not 
applied,  as  directed.  A  nurse  therefore,  assumes  an  awful  re- 
sponsibility, when  she  departs  from  her  province,  and  under- 
takes to  differ  in  opinion  with  the  physician,  or  neglects  his  or- 
ders. 

53.  On  the  regular  exhibition  of  medicine,  the  cure  very  often 
depends;  this  is  so  generally  admitted,  that  it  needs  no  illustra- 
tion.    In  many  cases,  life  itself  is  at  the  mercy  of  the  nurse,  as 
she  may  faithfully,  or  negligently  perform  her  duty.     How  ne- 
cessary is  it  then,  that  this  important  personage,  should  feel  the 
responsibility  attached  to  her  situation;  and  be  influenced  by  a 
conscientious  regard,  for  the  proper  fulfilment  of  the  duties,  her 
undertaking  has  imposed  upon  her? 

54.  In  insisting  on  the  entire  conformity  of  the  nurse  to  the 
directions  of  the  physician,  we  do  not  wish  to  be  understood  as 
declaring,  there  is  no  exception  to  the  rule.     On  the  contrary, 
the  patient,  as  well  as  the  physician,  are  occasionally  indebted 
to  the  nurse,  for  a  judicious  suspension,  or  perseverance  in  re- 
medies, beyond  the  strict  letter  of  her  orders;  and  especially, 
when  such  departures  have  proceeded,  from  a  genuine  exercise 
of  judgment;  and  not  from  a  wayward  determination  to  disobey. 
Now,  as  there  must  necessarily  exist  every  variety  of  constitu- 
tion, as  well  as  very  many  peculiarities,  or  idiosyncrasies,  no 
one  can  be  certain,  that  the  remedy  ordered,  shall  act  precisely 
as  desired;  consequently  the  departures  from  such  expectations 
may  be  great;  and  were  the  medicine  not  suspended,  or  some- 
times urged,  beyond  the  common  direction,  much  injury  might 
insue.  In  such  cases,  the  judicious  interference  of  the  nurse,  may 
be  highly  valuable,  and  fortunate. 

55.  But  these  cases,  rare  in  occurrence,  are  but  the  exceptions, 
and  do  not  in  the  least  interfere  with  the  general  rule;  and  to 
which,  it  is  the  bounden  duty  of  the  nurse,  most  scrupulously  to 
adhere.     She  is  therefore  not  only  bound  to  perform  most  ex- 
actly, what  she  is  ordered,  but  also,  to  do  nothing,  she  is  not  or- 
dered; for  as  much  mischief  may  result  from  the  one,  as  from  the 
other. 

3.   Of  giving  Drinks  and  Nourishment. 

56.  Greater  errors  are  generally  committed  in  the  use  of 
drinks  and  nourishment,  than  in  the  neglect,  or  mal-administra- 
tion  of  medicine.     It  is  supposed,  that  thirst  must  be  allayed 
whenever  importunate;  and  that  this  can  only  be  done,  by  pour- 
ing down  fluids,  without  regard  to  either  quantity  or  quality. 
This  error  is  sometimes  of  serious  moment,  as  it  not  only  over- 
loads the  stomach,  but  also  forces  it  to  regurgitate  the  supera- 


32  GENERAL    OBSERVATIONS. 

bundant  draughts,  to  the  great  inconvenience  or  injury  of  the  pa- 
tient. An  over-quantity  causes  oppression  and  restlessness;  an 
improper  quality  may  seriously  injure  from  its  entire  incompa- 
tibility. On  these  accounts,  the  nurse  should  never  depart  from 
the  quality  of  the  drink,  nor  ever  exceed  the  due  or  prescribed 
quantity. 

57.  Upon  these  points,  the  nurse  should  never  deviate  from 
express  directions;  for  should  she,  she  cannot  answer  that  im- 
mediate mischief  may  not  ensue.     Drinks  have  a  more  decided 
influence  upon  the  system  than  is  generally  admitted;  they  should 
therefore  be  subject  to  the  direction  of  the  physician,  as  much  as 
medicine  and  food. 

58.  From  a  vulgar  belief,  that  all  the  "  herb  teas,"  as  they 
are  called,  are  perfectly  innocent,  we  find  nurses  in  the  constant 
habit  of  employing  them,  without  the  sanction  of  the  physician; 
by  which  the  most  serious  evils  oftentimes  arise.     It  should 
be  recollected,  that  whatever  substance  possesses  a  power  to  do 
good,  may  also  have  a  power  to  do  injury,  if  it  be  injudiciously 
administered;  therefore,  the  whole  class  of  these  teas  should  be 
proscribed,  unless  expressly  ordered  by  the  medical  attendant, 
as  they  are  all  to  a  greater  or  less  extent,  of  a  heating  or  stimu- 
lating character. 

59.  Popular  feeling  is  in  favour  of  warm  or  hot  drinks,  and 
particularly  with  the  generality  of  nurses;  they  are  therefore  al- 
most constantly  exhibited,  especially  in  fever;  because  as  they 
suppose,  they  promote  perspiration.     This  error  should  be  done 
away  with ;  as  experience  has  proved,  that  as  a  general  rule,  they 
are  hurtful.     A  nurse  should  therefore  never  be  permitted  to 
prescribe  drinks,  any  more  than  medicine;  for  we  cannot  but  re- 
gard them  as  efficient,  or  injurious,  as  they  may  be  properly  or 
improperly  ordered. 

60.  We  may  make  similar  objections  to  the  manner  of  giving 
food  to  a  patient,  as  well  as  to  its  quality.     It  is  almost  always 
given  in  too  large  quantities,  or  too  frequently  repeated,  inde- 
pendently of  its  being  too  often  of  an  improper  quality.     The 
physician  alone  should  be  the  judge  of  these  matters;  and  his 
orders  should  be  obeyed,  most  strictly  and  literally.     An  error 
in  quantity,  it  should  be  remembered,  is  almost  equal  to  an  error 
in  quality;  for  every  particle  that  remains  unsubdued  by  the  sto- 
mach, becomes  offensive,  because  it  remains  unsubdued.     Or  if 
it  be  subdued,  it  may  be  extremely  injurious,  by  affording  too 
much  nutriment  to  the  system  at  a  moment  when  it  requires  ab- 
solute reduction.     So  important  then  is  the  due  administration 
of  nourishment,  that  the  nurse  should  never  be  left  to  her  own 
discretion. 


GENERAL    OBSERVATIONS.  33 


4.   Of  Cleanliness  in  the  Sick  Room. 

61.  No  single  agent  is  of  more  importance  in  a  sick  chamber, 
than  pure  air;  therefore,  to  prevent  its  becoming  foul,  every 
source  by  which  it  may  be  deteriorated  should  be  removed  in- 
stantly, when  practicable;  and  when  not,  it  must  be  compensated 
for,  in  the  best  manner  possible.     On  the  nurse,  this  task  will 
almost  exclusively  devolve;  she  must  therefore  be  mindful  not 
to  neglect  this  important  part  of  her  duty,  whenever  there  is  a 
necessity.     To  accomplish  this,  every  thing  that  can  emit  an  un- 
pleasant smell,  or  shall  evolve  an  injurious  gas,  must  be  taken 
away  with  all  convenient  speed.     The  evacuations  should  be  re- 
moved instantly  from  the  room ;  the  body,  and  the  bed-clothes 
should  be  as  frequently  changed^  as  circumstances  will  allow. 
Fresh  air  should  be  freely  admitted  into  the  room ;  no  filth  should 
be  permitted  to  accumulate  upon  the  floor,  the  tables,  the  bed, 
or  the  hearth. 

62.  All  the  vessels  employed,  either  for  medicine,  drinks,  or 
nourishment,  should  be  cleaned  the  instant  they  are  used;  con- 
sequently, the  same  vessel  or  spoon  should  never  be  used  twice 
without  its  being  first  cleaned,  unless  the  substance  for  which  it 
has  been  used  is  not  of  a  nature  to  become  offensive  to  any 
sense. 

63.  The  patient's  hands  and  face  should  be  frequently  cleansed; 
and  especially  when  warm,  by  wiping  them  with  a  towel  or 
napkin  wetted   with   cold   water  or  vinegar  and  water,  unless 
there  be  chilliness  present,  or  is  easily  excited  by  the  application 
of  any  thing  cold.     In  a  word,  every  thing  should  be  kept  as 
clean  and  as  sweet  as  the  nature  of  things  will  permit.  With  the 
same  view  to  comfort,  the  patient  should  have  his  mouth  fre- 
quently cleansed;  by  himself,  if  his  strength  will  permit;  and  by 
the  nurse,  when  this  fail.     This  attention  is  particularly  grateful 
in  the  decline  of  such  fevers  as  assume  what  is  called  the  typhus 
type;  that  is,  where  the  tongue  becomes  dry,  and  the  teeth  en- 
crusted.    For  this  purpose,  yeast  and  water  is  very  effectual;  or 
a  wash  made  of  a  tea-spoonful  of  the  sweet  spirit  of  nitre,  and  a 
table-spoonful  of  water.     The  latter  is  particularly  acceptable  to 
the  mouth  in  the  beginning  of  active  fevers;  where  the  tongue 
becomes  loaded  with  a  white  dense  fur,  or  is  coated  with  a  tena- 
cious slime.     The  patient  when  able,  finds  both  comfort  and 
amusement,  while  performing  this  office  for  himself,  by  means 
of  a  tooth-brush. 


34  GENERAL    OBSERVATIONS. 


5.    Of  quiet  in  the,  Sick  Room. 

64.  There  is  scarcely  any  thing  so  distressing  to  the  sick,  as 
noise.     It  should  therefore  be  the  nurse's  particular  study  to 
prevent  inconvenience  from  this  cause.     She  should  not  only 
be  of  quiet  habits  herself,  but  she  must  make  every  body  else 
conform  to  this  regulation.     A  talkative  nurse  is  a  great  evil; 
indeed  it  is  one  that  can  only  be  removed  sometimes,  by  the  re- 
moval of  the  nurse  herself;  and  it  were  always  better  to  do  so, 
than   to   have   the  patient  exposed  to  evils   arising  from  lo- 
quacity. 

65.  A  talkative  nurse  is  almost  sure  to  be  a  superstitious  one; 
and  if  so,  she  will  deal  out  her  forebodings  so  liberally  as  to  do 
decided  injury  to  the  patient.     In  the  sick  room  no  signs  should 
be  enumerated,  but  good  ones;  therefore  all  gossiping  recitals  of 
similar  cases  having  had  an  unfortunate  termination,  should   be 
most  carefully  prohibited.     All  unnecessary  conversation  should 
be  avoided,  as  the  sick  room  is  not  the  place  for  idle  colloquies. 
If  conversation  must  be  carried  on,  let  its  character  be  of  the 
cheerful  kind;  and  in  a  tone  of  sufficient  elevation,  that  the  pa- 
tient may,  if  he  become  interested,  thoroughly  comprehend  it. 
This  should  always  be  remembered.     But  as  a  general  rule,  the 
less  conversation  is  indulged  in,  the  better;  especially  when  the 
disease  is  of  the  acute  kind. 

66.  In  certain  conditions  of  the  nervous  system,  cheerful  con- 
versation is  frequently  highly  beneficial — and  in  such  cases,  an 
agreeable,  chatty,  and  well-instructed  nurse,  is  of  immense  value. 
But  even  in  such  cases,  the  topics  of  conversation  should  be  ju- 
diciously chosen,  and  their  duration  properly  regulated. 

67.  A  nurse  however,  may  be  annoying  to  the  patient  if  she 
be  not  over- talkative;  for  there  are  your  bustling  nurses,  who 
are  forever  putting  "  things  to  rights,"  without  ever  effecting  the 
object;  and  who  during  the  whole  time  make  so  much  clatter, 
that  the  patient  gets  no  sleep,  however  strong  the  desire;  or  else 
is  as  constantly  disturbed,  by  the  officious  employment  of  shovel, 
tongs,  or  dusting  brush. 

68.  We  are  aware  that  the  use  of  these  implements  cannot 
altogether  be  dispensed  with;  but  their  employment  can  certainly 
be  properly  timed. 

69.  It  were  better,  that  the  hearth  remained  unswept,  or  the 
fire   unrenewed,   than    the  patient  should  be  prevented  from 
taking  his  nap,  or  that  he  should  be  roused  from  a  sleep,  that 
might  be  highly  instrumental  to  his  recovery. 

70.  Indeed,  a  judicious  well-instructed  nurse,  knows  how  to 
take  advantage  of  the  times,  that  will  be  least  annoying  to  her 


GENERAL    OBSERVATIONS. 


patient.  There  should  therefore,  be  no  absolute  or  fixed  time, 
for  "  clearing  up  the  room;"  the  moment  that  will  create  the 
least  annoyance  to  the  sick,  should  be  the  only  one  selected.  We 
have  seen  your  nurses  of  absolute  routine  do  much  injury  by 
the  performance  of  this  office,  at  ill-chosen  periods.  The  con- 
dition and  comfort  of  the  sick  are  always  to  be  taken  into  con- 
sideration; and  ringing  the  changes  upon  the  unstable  shovel, 
tongs,  and  andirons,  should  be  postponed,  until  the  instant,  at 
which  the  patient  would  be  the  least  annoyed  by  it. 

71.  There  is  another  very  fruitful  source  of  noise,  and  annoy- 
ance in  the  sick  room,  and  which  is  very  rarely  attended  to; 
namely,  the  noise  of  a  creaking  shoe.     A  nurse  during  her  at- 
tendance upon  the  sick,  should  not  wear  a  shoe  that  will  yield 
the  slightest  sound;  for  she  can  always  command  such  as  will 
not;  or  if  she  cannot,  socks  can  constantly  be  procured,  and  with 
these  her  feet  should  be  cloathed. 

72.  We  may  enumerate  several  other  sources  of  unnecessary 
and  vexatious  noises  in  the  sick  room,  either  of  which  is  capable 
of  preventing  or  disturbing  sleep;  namely,  the  rattling  of  knives 
and  forks;  the  jingling  of  glasses;  and  the  clatter  of  spoons,  and 
plates.     Now,  as  these  can  never  be  necessary,  they  should  al- 
ways be  eschewed.     And  "  though  last,  not  least,"  in  this  ample 
enumeration,  is  the  frequent  opening  and  shutting  of  the  door 
of  the  sick  room.     This  common  and  certain  annoyance,  can 
always  be  avoided  by  the  following  observances. 

73.  1st.   Let  the  door  be  kept  open,  whenever  it  will  not  be 
desirable,  or  necessary  to  have  it  shut. 

74.  2d.   If  unavoidably  it  must  be  kept  shut,  let  its  being 
opened  be  productive  of  as  little  noise  as  possible;  1st,  by  having 
the  locks  in  good  repair;  and  2d,  having  them  to  open  easily; 
and  3d,  by  having  the  hinges  well  oiled. 

75.  3d.  Let  the  door  be  opened,  only  when  it  is  absolutely 
necessary  for  the  comfort  or  necessities  of  the  patient;  to  avoid 
unnecessary  openings,  permit  no  more  to  enter  the  room  than  is 
essential  to  the  nursing  of  the  patient;  because  you  will  have  to 
let  all  go  out  that  come  in  ;  and  each,  will  be  a  fresh  distur- 
bance. 

76.  4th.  Never  permit  the  door  to  be  opened,  while  the  pa- 
tient is  sleeping;  to  command  this,  we  are  told,  that  in  London, 
they  have  a  very  simple  mode  of  communicating  the  informa- 
tion, "that  the  patient  is  asleep,"  by  thrusting  the  feathered  end 
of  a  quill  through  the  key-hole.     It  would  be  highly  useful  to 
adopt  this  contrivance  in  this  country. 

77.  5th.   Exclude  all  visitors  from  the  sick  room,  however 
nearly  they  may  be  related  by  blood,  or  connected  by  friend- 
ship, whenever  such  prohibition  shall  be  essential  to  the  com- 


36  GENERAL    OBSERVATIONS. 

fort  or  safety  of  the  patient;  for  it  is  better  to  give  temporary 
offence,  than  to  produce  permanent  mischief. 

6.    Of  the  Ventilation  of  the  Sick  Chamber. 

78.  One  of  the  most  important  attentions  a  nurse  cati  bestow 
upon  the  sick  room,  is,  its  proper  ventilation.     As  regards  this 
essential  observance  itself,  it  matters  not,  whether  the  season  be 
hot  or  cold;  for,  in  this  instance,  we  merely,  but  distinctly  mean, 
changing  the  air  of  the  room — that  is,  the  removal  of  that,  which 
has  become  impure,  for  that  which  is  pure.     This  can  only  be 
done  with  certainty,  by  establishing  a  current  of  the  external 
air  through  the  sick  room,  by  the  doors  or  windows  being  opened 
to  a  sufficient  extent,  and  for  a  sufficient  length  of  time. 

79.  As  this  can  always  be  effected  by  proper  management 
without  risk;  and  as  it  is  of  the  first  consequence  to  the  patient, 
it  should  never  be  neglected.  The  frequency  of  this  renovation, 
or  rather  this  exchange  of  air,  must  be  regulated,  1st,  by  the 
season  of  the  year  5  2d,  by  the  state  of  the  weather;  and  3d,  the 
nature  of  the  disease. 

80.  1st.   The  season  of  the  year  will  influence  the  necessity 
of  ventilation ;  thus,  in  cold  weather,  or  in  winter,  the  air  of  the 
room  does  not  so  soon  become  vitiated  as  in  warm  weather,  or 
in  summer.    For  the  substances  capable  of  deteriorating  the  air, 
do  not  so  readily  become  decomposed  ;  and  the  circulation  of  the 
air  in  the  room  is  much  more  rapid  in  consequence  of  fire;  and, 
consequently,  more  frequently  changed.     Whereas,  in  summer, 
the  contrary  constantly  obtains;  hence,  the  greater  necessity  of 
giving  air  entrance  from  without,  by  means  of  the  windows  and 
doors. 

81.  2d.   The  state  of  the  weather,  as  regards  its  moisture  or 
dryness,  will  necessarily  influence  ventilation.     If  wet,  whether 
it  be  hot  or  cold,  it  will  never  be  proper  to  admit  the  external 
air  immediately  into  the  sick  room  suddenly,  or  in  large  quan- 
tities at  a  time.     The  capacity  to  ventilate  a  room  properly,  un- 
der such  circumstances,  will  necessarily  be  subject  to  many  con- 
tingencies, as  fortune,  or  poverty  may  prevail.     The  best  mode 
of  performing  this,  under  every  circumstance,  cannot  be  laid 
down;  much  must  be  left  to  the  discretion,  and  good  sense  of 
the  attendants. 

82.  3d.  The  disease  under  which  the  patient  may  be  suffering, 
will  also  have  its  influence  upon  the  air  of  his  chamber;  and  as 
a  general  rule  we  may  lay  it  down,  that  fever,  and  every  other 
acute  disease,  will  require  more  frequent  ventilation,  than  chro- 
nic affections.     Unless  the  latter  have  as  an  attendant,  profuse, 
or  offensive  discharges;  in  this  ca;e,  it  may  be  necessary  to 


GENERAL    OBSERVATIONS.  37 

change  the  air  more  frequently  than  even  in  fevers,  or  other 
acute  diseases. 

83.  Every  body  seems  to  be  aware  of  the  usefulness  of  chang- 
ing, or  purifying  the  air  of  a  sick  chamber;  some  arrive  at  this 
desirable  end  by  the  shortest  and  most  effectual  road ;  namely,  by 
the  admission  of  fresh  air  from  without;  while  others  suppose 
they  attain  this  change  by  chemical  decomposition.    Hence,  we 
have  open  windows  and  doors  in  the  one  instance ;  and  suffocat- 
ing vapours  in  the  other. 

84.  We  need  not  say  more  upon  the  first  of  these  modes  than 
we  have  already  done ;  on  the  latter,  it  may  be  well  to  offer  a 
few  observations,  as  its  effects  are  not  well  understood;  or  they 
certainly  would  not  continue  to  be  resorted  to.     Combustion  of 
every  kind  necessarily  destroys  in  proportion  to  its  extent  and 
continuance,  a  quantity  of  oxygen,  or  the  vital  principle  of 
the  atmosphere;  consequently,  wherever  this  process  is  per- 
formed,  the   air   becomes   less  pure,   by  the   loss   of  all   the 
oxygen  the  combustion  required,  to  carry  it  on.     Now,  when 
sweet   herbs,   as   they  are   called,   rosin,   sugar,   tar,   frankin- 
cense, &c.  are  burnt  in  the  sick  room,  the  air  of  that  room  loses 
a  certain  part  of  its  vital  air ;  and  is,  from  this  cause  alone,  less 
pure  than  it  was  before  the  burning  was  performed.    But  this  is 
not  all — for  the  air  now  has  in  it,  in  exchange  for  the  oxygen 
with  which  it  parted,  a  quantity  of  that  irrespirable  air,  called 
by  the  chemists,  carbonic  acid  gas,  or  fixed  air,  besides  a  disa- 
greeable odour,  and  other  gases  that  are  unfit  for  respiration. 
And  nearly  the  same  may  be  said  of  decomposing  vinegar  upon 
a  hot  shovel,  or  upon  live  coals.     These  methods  of  purifying 
the  air  of  a  sick  room,  should  therefore  be  strictly  prohibited. 

7.  Of  the  Temperature  of  the  Sick  Room. 

85.  There  is  ho  fault  in  nursing  more  common  than  over-heating 
the  room  of  the  sick.  The  dread,  that  the  patient  will  take  cold, 
unless  his  chamber  be  heated  almost  to  suffocation,  is  no  less 
common  than  the  fear  of  typhus,  and  the  apprehension  of  de- 
bility.    And  like  both  these  latter  terrors,  it  has  its  own  penal- 
ties.    For  in  almost  all  acute  diseases,  it  is  erring  on  the  wrong 
side ;  for  very  many  more  suffer  from  too  much  heat,  than  do 
from  too  little.     Light  should  be  constantly  excluded ;  at  least 
as  much  as  is  compatible,  with  proper  temperature,  and  venti- 
lation. 

86.  To  fever  patients,  nothing  is  so  grateful,  as  a  reduced 
temperature ;  nor  can  any  thing  be  more  proper.     One  of  the 
great  efforts  of  the  physician  in  fever,  is  the  reduction  of  the  ac- 


38  GENERAL    OBSERVATIONS. 

cumulated  heat  of  the  patient's  body;  and  one  of  the  best  agents 
for  this  purpose,  is  the  application  of  air  to  the  surface  of  the 
skin,  as  well  as  that  of  the  lungs,  when  it  is  of  a  lesser  tempera- 
ture than  the  body.  The  advantage  of  this  application  is  quickly 
perceived,  by  its  tranquillizing  influence  upon  the  restless  and 
agitated  patient;  by  his  skin  becoming  cooler;  his  breathing  less 
hurried,  and  his  pulse  less  frequent;  or,  perhaps,  by  his  quickly 
falling  into  a  refreshing  sleep,  or  breaking  out  in  a  universal 
perspiration. 

87.  But  on  the  other  hand,  if  the  heat  of  the  room  be  equal, 
or  nearly  equal  to  the  temperature  of  his  skin,  the  reverse  of  all 
this  is  sure  to  happen — an  aggravation  of  every  symptom  will 
certainly  follow.     It  therefore  becomes  the  bounden  duty  of  the 
nurse,  to  so  regulate  the  heat  of  the  room,  as  it  shall  be  con- 
stantly below,  by  a  number  of  degrees,  that  of  the  patient's  skin. 
We  look  upon  a  thermometer  to  be  a  necessary  appendage  to  a 
sick  room — for  by  this  instrument  alone,  can  we  be  certain  of 
either  an  increase,  or  decrease  of  temperature ;  our  feelings  are 
fallacious  guides. 

88.  At  a  season  when  fires  are  not  in  requisition,  an  attempt 
is  frequently  made  to  warm  the  room  upon  any  sudden  reduc- 
tion of  atmospheric  temperature,  by  burning  of  charcoal  in  the 
room.     Let  this  never  be  practised  ;  as  it  is  oftentimes  replete 
with  instant  and  imminent  danger. 

8.  Regulating  the  Warmth  of  the  Patient. 

89.  At  first  sight  it  might  be  supposed,  that  this  part  of  a 
nurse's  duty  would  regulate  itself — but  it  is  not  so.  There  is  no 
one  point  in  nursing,  that  has,  so  little   system,  or  that  is  di- 
rected with  so  little  judgment  as  the  warmth  of  the  patient. 
Nurses  upon  this  point,  have  no  principles  to  direct  them  ;  or 
none  at  least,  that  are  conformable  to  the  proper  treatment  of  the 
patient.     It  never  becomes  a  subject  of  thought,  that  the  patient 
can  be  benefited  or  injured  by  a  particular  quantity  of  bed-clothes, 
or  by  any  particular  temperature  of  his  body,  provided  he  does 
not  complain  of  feeling  cold. 

90.  If  the  patient  declare  he  feels  too  cool,  more  covering  is 
heaped  upon  him;  and  sometimes,  without  mercy.     To  relieve 
the  sensation  of  cold  by  additional  clothes,  is  always  proper  ; 
and  the  nurse  in  her  attempt  to  restore  pleasurable  sensation  by 
this  means,  acts  in  strict  conformity  to  principle,  but  without 
knowing  it;  and  so  far  so  good.     But  here  her  anxiety  ceases, 
and  her  judgment  is  no  longer  exercised;  for  after  reaction  has 
taken  place,  and  the  heat  upon  the  surface  has  become  exces- 


GENERAL    OBSERVATIONS.  39 

sive,  she  never  dreams,  that  it  is  as  beneficial  to  lower  the  tem- 
perature, as  it  was  proper  and  grateful  to  raise  it,  when  it  was 
too  low ! 

•91.  She  refuses  to  comply  with  the  earnest  prayer  of  the  al- 
most burnt  up  patient,  to  "remove  some  of  his  covering;"  but 
on  the  contrary,  insists  it  would  be  his  death  were  she  to  do  so, 
or  he  would  take  cold.  He  is  therefore  obliged  to  submit,  until 
the  heat  .becomes  so  intolerable,  that  he  bids  defiance  to  re- 
straint, and  removes  the  offending  covering  by  main  force  ;  and 
he  effects  oftentimes  by  this  independence,  such  a  reduction  of 
temperature,  as  will  perhaps  now  induce  the  skin  to  throw  out  a 
free  perspiration. 

92.  It  is  true,  that  the  poor  nurse  was  anxious  for  this  very 
result ;  and  the  very  object  of  her  refusal  to  remove  the  super- 
fluous bed-clothes,  was  to  induce  the  sweating,  so  quickly  effected 
by  the  very  opposite  means.     She  is  not  aware,  that  there  is  a 
sweating  temperature;  and  that  when  this  is  exceeded,  perspira- 
tion will  cease  if  it  have  been  present ;  or  that  it  will  not  take 
place  during  its  continuance.  The  rule  therefore  upon  this  point 
is  plain;  that  the  patient  should  no  more  be  allowed  to  complain 
of  too  much  heat,  without  an  attempt  at  its  reduction,  than  he 
should  be  permitted  to  remain  chilly,  when  it  is  possible  to  remove 
it.     In  a  word,  we  should  try  to  create  the  pleasurable  sensation 
of  healthy  temperature;  and  this  can  very  often  be  done  by  the 
proper  adjustment  of  the  covering;  and  this  without  incurring 
the  smallest  risk.     Therefore,  the  quantity  of  covering,  should 
always  be  made  subservient  to  the  sensations  of  the  patient. 

9.    The  Examination  and  Preservation  of  the  Excretions. 

93.  This  duty  is  almost  constantly  neglected ;  not  being  ca- 
pable herself  of  drawing  conclusions  from  the  varied  appearances 
of  the  evactuations,  the  nurse  very  often  does  not  even  inspect 
them,  much  more  preserve  them  for  the  physician.*     Or  if  she 
have  seen  them,  her  account  of  their  appearance  is  expressed  so 
vaguely,  that  no  satisfaction  can  be  obtained,  by  any  extent  or 
ingenuity  of  interrogation.     They  have  for  the  most  part,  a  set 
of  terms  to  express  the  colours  of  the  stools,  and  which  may  be 
every  way  satisfactory  to  themselves,  but  which  are  altogether 
unintelligible  to  the  physician;    such  as  "natural;"    "very 
healthy  ;"   "  very  heavy  ;"  "  very  slimy  ;"  "  very  black,"  &c. 
&c.     Now,  we  have  frequently  found  by  inspection,  that  their 
"natural"   and   "very  healthy,"   were  highly   bilious;    their 

*  We  almost  constantly  direct  the  keeping  of  the  evacuations;  but  for  this 
purpose  they  should  not  be  retained  in  the  sick  room. 


40  GENERAL    OBSERVATIONS. 

"  very  heavy,"  to  mean  no  more  than  very  offensive ;  their 
"  very  slimy,"  to  be  pure  bile,  without  a  particle  of  the  mucus 
of  the  bowels,  which  you  were  from  their  description,  prepared 
to  meet ;  and  their  "  very  black/'  is  almost  sure  to  prove 
brown,  &c. 

94.  The  same  or  similar  errors  are  constantly  committed  in 
their  accounts  of  the  appearance  of  the  urine,  when  inquired  for. 
It  is  "very  white;"  "very  red;"  "very  black;"  "very  thick," 
&c.     The  "  very  white,"  means  transparent,  or  of  the  colour  of 
water;  "  very  red,"  means  that  it  has  deposited  a  red  sediment; 
"very  black,"  means,  when  it  is  highly  charged  with  bile;  and 
"very  thick,"  means,  that  after  standing  it  has  become  turbid, 
though  perfectly  clear  and  thin,  when  it  was  evacuated. 

95.  On  this  account,  we  never  depend  upon  their  descriptions 
of  the  excretions;  and  we  are  in  the  constant  habit  of  ordering 
them  to  be  preserved  that  we  may  judge  for  ourselves;  but  we 
are  constrained  to  say,  that  too  little  regard  is  paid  to  such  or- 
ders, though  it  is  the  duty  of  the  nurse  to  obey  them,  as  the  in- 
spection of  them  is  highly  important. 

10.    Of  the,  Patient's  sitting  up. 

96.  An  overweening  anxiety  on  the  part  of  the  nurse  to  have 
the  patient  sit  up,  is  often  productive  of  serious  consequences.  It 
is  imagined   and  declared,  that   "the  patient  can  never  gain 
strength  while  he  lies  in  bed". — hence,  he  is  forced  to  ill-timed 
exertion  by  the  importunity  of  the  nurse,  or  of  his  friends,  at  a 
time  that  may  occasion  him  to  faint,  or  to  endanger  a  relapse. 
They  seem  to  forget,  that  this  change  of  position  requires  a  cer- 
tain quantum  of  strength  to  perform  it;  and  that  it  cannot  be  done 
if  that  be  absent.    Now,  in  cases  of  long,  or  even  of  short,  very 
enfeebling  diseases,  the  strength  is  oftentimes  so  prostrated,  as  to 
require  much  care,  to  either  husband,  or  improve,  the  remaining 
little.  Yet  the  patient  is  often  required  to  expend  his  little  stock, 
to  gratify  a  false  theory  of  the  nurse,  or  friends.     In  this,  they 
are  only  directed  by  a  popular  and  vulgar  error;  for  it  is  evi- 
dent, that  if  the  patient's  strength   has  been  so  prostrated   at  a 
certain  period,  that  even  the  nurse  would  have  deemed  it  impru- 
dent to  have  attempted  it,  it  would  be  madness,  to  insist  upon 
its  performance,  if  it  had  not  improved;  while  on  the  other  hand, 
it  is  equally  clear,  that  if  he  be  able  to  do  this  after  a  short  in- 
terval by  care,  that  he  must  have  acquired  some  strength;  con- 
sequently, it  gives  contradiction  to  the  position,  that  "the  pa- 
tient cannot  gather  strength,  while  he  lies  in  bed." 

97.  Sitting  up  after  illness,  is,  to  all  intents  and  purposes,  ex- 
ercise.    Now,  during  an  approaching,  or  even  during  a  confirm- 


GENERAL    OBSERVATIONS.  .41 

ed  convalescence,  exercise  to  be  useful,  must  he  most  carefully 
employed;  lest  its  excess,  and  this  even  in  a  trifling  degree,  be 
productive  of  the  most  serious  consequences.  For  exercise  is  a 
remedy;  and  a  remedy  of  great  power;  consequently,  if  its  dose 
be  not  properly,  and  opportunely  prescribed,  its  effects  may,  like 
an  over  dose  of  any  other  active  remedy  be  followed  by  irreme- 
diable evils.  We  wish  we  could  persuade  the  advocates  for  this 
hap  hazard  sitting  up,  to  view  it  in  this  light;  for  did  they, 
much  mischief  would  be  saved. 

98.  The  rules  for  sitting  up,  are  in  strict  conformity  with 
those,  which  govern  every  other  remedy ;  namely,  that  its  dose, 
is  to  be  regulated,  by  its  necessity;  the  strength  of  the  patient; 
and  its  effects.    It  must  generally  be  looked  upon  as  a  stimulant 
of  great  power;  and  consequently,  must  be  used  as  such.     To 
prove  this,  it  is  only  necessary  to  examine  the  patient's  pulse 
under  its  influence,  and  it  will  be  constantly  found,  when  em- 
ployed at  the  time  of  great  vascular  excitement,  to  be  from  ten 
to  twenty  strokes  in  the  minute  more,  in  the  sitting  up,  than  in 
the  supine  position  of  the  body;  consequently,  proving  its  sti- 
mulant power,  and  oftentimes,  its  unfriendly  effects  in  fever. 

99.  And  when  resorted  to  in  cases  of  great  debility,  the  heart 
performs  its  functions  with  such  rapidity,  but  with  such  speedy 
exhaustion,  that  fainting  is  often  induced  in  a  very  few  minutes.* 
But  this  condition  of  the  system  may  be  produced,  by  the  dose 
being  ill-timed,  or  too  long  continued.     Now  in  either  case,  mis- 
chief, and  sometimes,  very  lasting  mischief,  ensues.     It  there- 
fore follows,  that  much  care  is  required,  in  getting  the  patient 
out  of  bed;  and  that  it  should  be  considered  as  a  great  qualifica- 
tion in  a  nurse,  who  can  prescribe  this  remedy  advantageously, 
to  her  patient. 

100.  It  is  a  very  common  error  with  nurses,  to  permit  their 
patients  to  sit  up  too  lojig  at  a  time;  indeed,  in  general  they 
seem  to  have  no  other  rule  upon  this  point,  than  to  let  them  re- 
main as  long  as  they  can  support  the  fatigue;  consequently,  all 
the  good,  that  might  have  been  derived  from  the  change  of  po- 
sition, is  defeated  in  an  instant,  by  a  state  of  faintness  being  in- 
duced. The  patient  should  therefore  never  remain  sitting  up  one 
moment  longer,  than  while  his  sensations  continue  to  be  agree- 
able; for  if  he  be  not  instantly  replaced  in  his  bed  when  these 
pleasurable  feelings  cease,  he  will  be  sure  to  suffer  from  exhaus- 
tion, if  not  from  fainting.     It  is  therefore  very  much  better  that 
the  patient  sit  up  several  times  during  the  day  when  he  can  sup- 

*  Fainting  is  also  produced,  by  the  blood  retiring  from  the  brain  upon 
the  patient  being  placed  in  an  erect  position;  leaving  too  little  in  this  organ 
for  the  purposes  of  due  stimulation  of  the  nervous  system. 

6 


42  GENERAL    OBSERVATIONS. 

port  it,   than  he  should  sit  up  one  minute  after  he  finds  his 
strength  flagging. 

101.  There  is  another  error  committed  during  the  sitting  up 
of  the  patient,  which  is  every  way  calculated  to  destroy  any  good 
the  getting  out  of  bed  promises;  namely,  surrounding  him  with 
bed-clothes  in  such  quantities  as  to  oppress  him  with  their  weight, 
as  well  as  to  exhaust  him,  by  their  heat.     This  practice  should 
be  carefully  avoided,  if  any  good  is  to  result  from  his  change  of 
position.   Again,  the  fear  of  his  "  catching  cold,"  which  induced 
the  nurse  to  stifle  him  with  bed-clothes,  also  leads  her  to  the 
shutting  out  from  the  room  every  particle  of  fresh  air,  by  block- 
ing up  every  avenue  to  its  admission.     The  patient,  in  conse- 
quence, is  obliged  to  breathe  both  a  heated  and  impure  atmos- 
phere; this  quickly  exhausts  him,  and  he  soon  begs  to  be  re- 
stored to  his  bed.     There  is  no  possible  necessity  for  this  over- 
caution;  all  that  is  proper  to  guard  against,  is  a  current  of  cold 
air  immediately  upon  the  patient,  and  preventing  chilliness. 

11.    Of  the  Making  of  the.  Bed. 

102.  This  necessary  arrangement,  is  almost  always  badly  con- 
ducted.  It  is  seldom  performed  with  either  comfort  or  advantage 
to  the  patient;  as  his  immediate  condition,  is  too  often  lost  sight 
of.  He  is  frequently  taken  out  of  bed,  and  made  to  sit  in  a  chair, 
while  the  bed  is  beating  up,  and  the  clothes  are  spreading.  Dur- 
ing this  period,  he  either  becomes  much  exhausted,  or  absolute- 
ly faints.* 

•  The  following  instance  of  this  kind,  was  so  extensive  in  mischief,  that  we 
think  it  proper  to  relate  it,  as  it  may  perchance  serve  as  a  warning  to  the  in- 
discreet nurse,  or  to  the  officious  friend.  In  the  summer  of  1825,  we  attended 
a  young  gentleman  with  a  high  grade  of  bilious  fever,  and  from  which  he  was 
slowly,  but  certainly  recovering.  He  however  was  still  extremely  weak;  though 
he  was  now  permitted  to  use  a  more  nourishing  diet  than  he  had  hitherto 
been  allowed,  and  with  the  most  marked  advantage.  Quiet  and  rest  were  still 
recommended;  he  was  allowed  to  be  shifted  to  different  portions  of  his  mat- 
tress, whenever  the  part  he  was  lying  on,  became  unpleasantly  warm,  as  the 
weather  was  very  hot. 

A  friend  called  to  see  him;  and  finding  him  still  weak,  and  very  much  re- 
duced, declared  that  unless  he  were  taken  out  of  bed,  and  permitted  to  have 
the  air  circulate  around  him,  he  could  never  expect  to  gain  strength;  his  nurse 
was  of  the  same  sentiment,  and  they  urged  their  opinions  so  strongly,  that  the 
mother  of  the  patient  yielded,  though  reluctantly,  as  it  was  contrary  to  the 
express  commands  we  had  given  but  a  few  hours  before,  and  which  she  was 
every  way  willing  to  obey. 

Accordingly  arrangements  were  immediately  made  for  the  sitting  up  of  the 
patient;  he  was  lifted  out  of  bed,  and  placed  in  an  easy  chair,  where  he  had 
not  been  more  than  five  minutes,  before  he  fainted.  His  syncope  was  so  ex- 
treme, and  so  long-continued,  that  he  was  considered  as  absolutely  dead;  for 
on  our  arrival  to  his  assistance,  we  were  informed  before  we  went  up  stairs, 


GENERAL    OBSERVATIONS.  43 

103.  It  should  therefore  be  a  constant,  and  a  never  to  be  de- 
parted from,  rule,  that  the  patient  is  not  to  be  taken  up  at  the 
risk  of  fainting;  more  especially  as  this  too  early  rising  can  never 
be  necessary.     For  if  the  patient  is  obliged  to  be  moved  for  the 
purpose  of  refreshing  hisx  bed  by  a  change  of  its  linen,  &c.  he 
should  be  lifted  carefully  from  it,  and  placed  upon  one  adjusted 
by  its  side;  or  in  cases  of  still  greater  debility,  he  should  only 
be  removed  to  the  other  side  of  the  bed,  while  the  one  he  has 
just  left  is  undergoing  the  necessary  change,  and  to  which  he 
may  be  soon  restored,  to  enjoy  the  alteration  just  effected. 

104.  It  would  be  a  most  profitable  arrangement  for  the  sick 
with  fever,  or  other  acute  diseases,  if  a  mattress  could  be  substi- 
tuted for  the  feather  bed ;  than  which  there  is  nothing  more  un- 
friendly to  the  disease,  or  more  destructive  to  the  comfort  of  the 
patient.     The  advantages  of  the  mattress  over  the  bed,  are  as 
evident  to  those  who  will  reflect  upon  the  subject,  as  the  incon- 
veniences of  the  latter  are  notorious;  but  so  inveterate  is  habit, 
that  substituting  one  for  the  other,  with  the  generality  of  the 
people  in  this  country,  is  rarely  to  be  accomplished.     Besides 
the  obvious  advantages  of  the  mattress  to  the  patient,  we  may 
reckon  the  facilities  it  would  afford  to  the  nurse;  to  her,  much 
trouble  would  be  saved  by  its  general  adoption ;  yet  strange  to 
say,  she  almost  always  gives  the  preference  to  the  feather  bed. 
And  it  is  one  of  our  tests,  of  a  well-instructed  and  a  reasoning 
nurse,  when  she  decides  in  favour  of  the  mattress. 

105.  The  necessity  of  beating  up  the  bed,  or  newly-spreading 
the  mattress,  must  be  regulated,  by  the  nature  of  the  disease,  and 
by  the  strength  of  the  patient.    In  fever  it  should  be  done  twice 
a  day,  if  the  patient  have  sufficient  strength  to  bear  it  without 
risk;  more  seldom  as  this  may  be  upon  the  wane.     But  when 
unable  to  leave  his  bed  for  this  purpose,  he  may  be  shifted  from 
side  to  side,  as  directed  above ;  (especially  in  warm  or  hot  wea- 

that  this  was  the  case.  We  gave  into  the  belief,  ourselves  for  a  moment,  and 
looked  upon  the  case  as  altogether  hopeless.  Yet  we  thought  it  proper  to  try 
means,  though  a  full  half  hour  had  elapsed  from  the  first  moment  of  fainting. 
Accordingly,  hot  wrappers,  bricks,  jugs  of  warm  water,  volatile  alkali  to  the 
Schneiderian  membrane  and  lips,  as  well  as  to  the  rectum  by  an  enema,  &c. 
were  instantly  resorted  to;  and  after  about  twenty  minutes  of  uninterrupted 
exertions  had  been  employed,  we  had  the  pleasure  to  hear  him  make  a  deep 
inspiration  and  expiration.  These  were  repeated,  and  soon  followed  by  an 
evident  pulsation  of  the  heart.  But  not  to  dwell,  he  gradually  gave  evidences 
of  returning  animation;  and  eventually  life  was  restored.  He  remained  after 
this  in  a  state  of  great  feebleness  for  a  long  time;  but  eventually  recovered. 

In  this  case  I  attributed  much  efficacy  to  the  injection;  consisting  of  two  tea- 
spoonfuls  of  the  pure  ammonia  water,  and  a  pint  of  warm  water;  as  the  favoura- 
ble signs  took  place  almost  immediately  after.  My  present  impression  is,  that 
this  use  of  the  aq.  ammon.  purae,  has  not  heretofore  been  resorted  to,  in  cases 
of  extreme  syncope,  or  of  asphyxia;  it  may  deserve  further  trials. 


44  GENERAL    OBSERVATIONS. 

ther,)  as  often  as  his  inclination  may  prompt,  or  his  strength 
will  permit ;  provided  this  be  not  performed  while  he  is  sweating. 

12.  Of  the  Proper  Using  of  the  Utensils  far  Evacuations. 

106.  On  the  proper  employment  of  the  several  utensils  essen- 
tial to  the  sick  room,  much  of  the  comfort  of  the  patient  will 
depend,  if  it  be  not  even  instrumental  to  his  recovery.     One  of 
the  cardinal  objects  in  the  management  of  the  sick,  is,  to  avoid 
all  unnecessary  fatigue;  and  this  should  never  be  lost  sight  of, 
even  in  the  smallest  details  of  the  art     One  great  source  of  fa* 
tigue,  is  the  mismanagement  of  the  patient  during  his  evacuations. 
He  is  forced  to  rise  from  his  bed  for  the  performance  of  these 
necessities,  at  a  time  he  can  oftentimes  ill  support  the  expense  of 
strength  it  will  require ;  and  sometimes  it  is  completely  exhaust- 
ed, before  they  are  completed. 

107.  To  prevent  inconveniences  so  serious,  yet  so  constantly 
recurring,  as  much  as  possible,   requires  on   the  part  of  the 
nurse,  an  entire  acquaintance  with  her  duties,  and  the  best  mode 
of  performing  them ;  and  more  rests  with  her  in  this  particular 
than  is  commonly  imagined.     Some  of  them  require  that  every 
exertion  should  come  from  the  patient;  while  others  manage  the 
various  operations  with  great  dexterity,  and  at  a  small  expense 
of  his  strength.     The  latter  class  possess  feeling,  knowledge, 
and  experience ;  for  it  requires  all  to  perform  these  offices,  to  the 
greatest  advantage.     Hence,  the  immense  value  of  some  nurses 
over  others. 

108.  As  a  general  rule,  the  patient  when  feeble  should  not  be 
made  to  leave  his  bed,  when  he  can  without  much  inconvenience 
perform  his  offices  in  the  bed.    For  this  purpose,  a  bed-pan,  and 
an  urinal  are  very  necessary  appendages  to  the  sick  chamber ; 
indeed  it  is  not  properly  furnished  without  them.  We  are  aware, 
that  the  nurse  will  plead  in  extenuation  of  the  patient's  getting 
up,  that  he  neither  can  nor  will,  use  the  pan  in  bed — indeed  we 
have  witnessed  this  opposition  in  many  instances;  but  at  the 
same  time  we  scarcely  ever  failed  to  find,  it  was  owing  to  the 
mal-adroitness  of  the  nurse,  rather  than  to  a  rebellious  disposi- 
tion on  the  part  of  the  patient.     With  a  little  management  and 
perseverance,  this  difficulty  is  almost  always  surmounted. 

109.  Before  the  pan  is  offered  to  the  patient,  a  pillow  should 
be  placed  under  his  back,  so  as  to  prevent  its  becoming  hollow, 
and  consequently  unsupported.  We  have  almost  constantly  found 
this  want  of  support  to  be  the  ground  of  complaint  against  the 
pan;  but  it  is  certainly  remedied  in  this  way. 

110.  For  the  purpose  of  passing  urine,  the  patient,  (male  or 
female,)  should  not  be  permitted  to  rise,  when  strength  is  upon 


GENERAL    OBSERVATIONS.  45 

the  wand,  or  when  it  is  much  exhausted,  if  the  proper  utensils 
can  be  procured.  And  this  can  almost  always  be  done,  if  due 
attention  be  paid  for  this  purpose. 

111.  Of  apparently  minor  consequence,  though  of  equal  im- 
port, is  the  manner  in  which  the  patient  is  forced  to  receive  his 
drinks;  for  though  no  single  effort  to  receive  drink,  is  equal  to 
the  exertion  of  using  the  pan,  it  is  nevertheless  oftentimes  very 
distressing  to  the  patient  from  the  manner  in  which  it  is  given; 
and  as  this  is  repeated  very  frequently  in  fever,  and  other  acute 
diseases,  the  sum  of  exertion  after  a  little  while,  will  be  found 
very  considerable,  and  highly  injurious  to  the  patient. 

112.  A  very  large  majority  of  nurses  oblige  their  patients  to 
rise  in  the  bed  to  receive  their  drinks;  this  is  owing  to  the  im- 
proper form  of  the  vessel  from  which  they  receive  it;  for  did 
they  not  raise  themselves,  or  suffer  themselves  to  be  raised,  the 
clothes  would  receive  as  much  of  the  fluid,  as  the  patient.     A 
tumbler,  a  wine-glass,  a  bowl,  or  a  cup,  are  the  common  vehicles 
of  drink ;  neither  of  which,  should  ever  be  employed  in  a  well 
regulated  sick  room,  while  the  patient  is  confined  to  his  bed. 
The  sick-cup,  as  it  is  called,  should  alone  convey  drink  to  him  ; 
for  by  it  all  fatigue  is  spared ;  and  he  can  receive  it  in  any  posi- 
tion of  his  body,  without  the  slightest  exertion.     They  can  be 
procured  from  almost  any  china  store, 

13.    Of  Skill  in  Applying  and  Dressing  of  Blisters. 

113.  This  is  a  most  useful,  and  important  part  of  a  nurse's 
duty ;  and  it  is  one,  of  which  she.  should  never  be  ignorant,  espe- 
cially, as  the  efficacy  and  success  of  the  application,  as  well  as 
the  comfort  of  the  patient  are  all  concerned  in  it.     It  is  not  the 
mere  application  of  the  plaster  to  the  spot  indicated,  that  ensures 
the  best  effects  of  this  remedy — something  more  is  required ; 
and  this  something,  the  nurse  should  be  acquainted  with.  Thus, 
when  the  circulation  is  languid,  and  the  sensibility  much  dimi-*- 
nished  in  the  part,  it  would  be  almost  idle  to  bind  the  plaster  to 
it  in  the  common-  way,  or  without  preparation  of  the  spot  to 
which  it  is  affixed,  by  first  rubbing  it  well  with  some  highly  sti- 
mulating substance. 

114.  But  this  is  not  all  that  is  required,  to  secure  the  best 
offices  of  blisters.     Dr.  Watt*  tells  us  "  that  when  a  blister  is  to 
be  applied,  it  ought  to  be  large  and  spread  so  thick  as  to  rise  in 
as  short  a  period  as  possible.   In  this  respect,  practitioners  them- 
selves commit  very  great  errors.     If  a  blister  rise  at  all,  they 
think  every  purpose  is  served  that  a  blister  can  accomplish;  but 

*  Treatise  on  Chincough,  &c.  p.  244. 


46  GENERAL    OBSERVATIONS. 

this  is  by  no  means  the  case.  A  blister  made  too  weak  or  spread 
too  thin,  soon  dries,  and  merely  raises  the  cuticle,  and  even  to 
do  this,  requires  a  considerable  length  of  time;  whereas  one 
thickly  spread,  with  well  made  plaster,  raises  not  only  the  cuti- 
cle, but  also  the  rete  mucosum,  and  does  it  too  in  a  much  shorter 
period."  "I  am  fully  convinced,  from  long  experience,  that 
there  is  a  very  great  difference  in  blisters  according  to  the  man- 
ner in  which  they  are  made  up  and  applied.  The  practice  of 
putting  dry  flies  on  the  surface  of  the  blister,  is  also  a  bad  one. 
If  the  flies  be  good,  and  the  plaster  well  prepared,  it  requires  no 
such  assistance.  Besides,  the  loose  particles  of  the  flies  are  apt 
to  insinuate  themselves  into  the  skin  and  adhere  to  the  sore  after 
the  blister  is  removed,  giving  the  patient  very  unnecessary  un- 
easiness and  often  producing  strangury." 

115.  It  must  therefore  be  looked  upon  as  a  rule,  that  the  ope- 
ration of  stimulating  the  part  be  always  performed,  under  such 
circumstances;  and  that  it  is  the  province  of  every  nurse,  pro- 
perly so  called,  to  be  acquainted  with  it,  and  to  comply  with  it. 
If  she  be  well  instructed  in  her  art,  she  will  at  once  select,  and 
apply,  the  proper  substances.    If  she  be  not,  she  must  be  direct- 
ed to  the  use  of  the  spirit  of  turpentine ;  of  hartshorn ;  or  Cayenne 
pepper  and  brandy,  &c.  for  this  purpose ;  with  either  of  these, 
the  part  on  which  it  is  designed  to  place  the  blister,  should  be 
well  rubbed,  for  four  or  five  minutes  before  it  is  bound  on. 

116.  But  on  the  other  hand,  an  ignorant  nurse  will  sometimes 
do  mischief,  by  employing  these  substances,  where  the  circula- 
tion is  active,  and  where  the  sensibility  is  perhaps  even  exalted; 
merely,  because  she  has  seen  them  do  good  where  they  were  ne- 
cessary; and  thus  proving  herself  altogether  unacquainted  with 
the  reason  for  their  application — we  have  witnessed  several  mis- 
takes of  this  kind,  to  the  great  annoyance  of  the  patient. 

117.  An  improvement  of  great  consequence  in  the  application 
of  blisters,  has  lately  been  made,  by  substituting  adhesive  plas- 
ter  for  bandages.     This  mode  is  particularly  valuable,  when 
the  blister  is  to  be  applied  to  any  other  part,  than  the  extremi- 
ties.    Thus,  all  the  inconveniencies,  and  the  confinement  which 
attach  to  bandages,  is  entirely  avoided  when  the  plaster  is  to  be 
applied  to  the  chest,  abdomen,  back,  or  between  the  shoulders. 
Simple  as  the  method  is  when  sticking  plaster  is  used,  we  have 
found  its  utility  entirely  defeated,  by  the  mere  routine  nurse 
not  understanding  its  proper  management.     This  has  happened 
from  the  almost  universal  belief,  that  a  blister  will  not  draw 
without  the  part  on  which  it  is  to  be  placed,  is  previously  wetted 
with  vinegar — this  therefore  is  done;  and  the  plaster  is  applied, 
and  all  is  supposed  to  be  right.     But  upon  the  examination  of 
the  blister,  at  the  allotted  time  for  its  drawing,  it  is  found  any 


GENERAL    OBSERVATIONS.  47 

where,  but  where  it  was  designed  to  have  been  placed ;  for  the 
part  being  wet,  the  adhesive  plaster  would  not  stick ;  and  the 
blister  became  at  the  mercy  of  every  motion  of  the  patient.  And 
time,  perhaps  precious  time,  has  been  lost;  or  a  part  not  intend- 
ed to  be  subjected  to  its  operation,  been  made  to  endure  the  pain, 
but  without  the  smallest  advantage  to  the  complaint  for  which  it.' 
was  designed  to  relieve. 

118.  It  may  be  proper  to  remark,  that  with  grown  people, 
but  especially  with  males,  it  would  always  be  best  to  remove  the 
hair  by  shaving  the  part  designed  to  be  the  seat  of  the  blister, 
even  when  the  common  mode  of  applying  it  is  adopted;  but  that 
it  becomes  absolutely  necessary,  when  the  sticking  plaster  is 
used,  if  the  part  be  supplied  with  it. 

119.  As  we  consider  the  use  of  the  adhesive  plaster  to  confine 
a  blister  to  have  great  advantages  over  bandaging,  we  will  detail 
the  two  modes  of  employing  it.     The  first,  and  most  common, 
though  not  always  the  best,  is  to  have  the  margin  of  the  plaster 
spread  from  half  to  three-quarters  of  an  inch,  with  the  adhesive 
plaster.   If  the  blister  be  small,  half  an  inch,  (as  with  children,) 
will  generally  be  sufficient;  if  larger,  three-quarters  may  be  ne- 
cessary ;  but  if  very  large,  it  may  require  an  inch   of  margin. 
When  thus  prepared,  its  edges  are  to  be  snipped  by  scissors  in  a 
number  of  places,  to  the  depth  of  the  sticking  plaster,  to  secure 
its  sitting  better  on  the  part.     It  must  then  be  held  over  a  few 
hot  coals,  until  the  adhesive  plaster  becomes  sufficiently  softened, 
to  insure  its  sticking  well  to  the  skin. 

120.  The  other  plan  is,  to  have  strips  of  spread  sticking  plas- 
ter, of  such  lengths  as  shall  extend  two  inches  at  least  over  each 
margin  of  the  blister  after  it  is  applied  to  the  part;  the  breadth 
may  be  three-quarters  of  an  inch.     In  this  case  the  blistering 
ointment  covers  the  whole  surface  of  the  plaster.     The  mode  of 
applying  the  adhesive  strips,  is  by  warming  them  well,  and  then 
making  them  across  the  blister,  either  directly  across  each  end, 
or  in  the  direction  of  its  two  diagonals.     If  the  plaster  be  very 
large,  or  the  patient  very  restless,  three,  or  even  four  strips, 
may  be  necessary.     To  secure  the  adhesion  of  the  plaster,  the 
skin  upon  which  it  is  to  be  applied,  should  be  perfectly  dry ;  if 
it  be  moist  with  perspiration,  a  little  common  flour  dusted  upon 
it,  and  wiped  off,  will  effectually  serve  the  purpose  proposed. 
Should  the  blistering  part  of  the  plaster  be  made  of  the  dry  flies, 
it  is  best  to  moisten  its  surface  carefully  with  a  little  warm  vine- 
gar or  brandy;  taking  care  not  to  touch  the  margin  with  it,  if  it 
be  spread  with  adhesive  plaster,  or  it  will  prevent  sticking. 

121.  When  blisters  are  applied  to  the  legs,  it  is  best,  especially 
if  the  patient  be  restless,  to  draw  stockings  over  them,  which  will 
effectually  prevent  their  being  disturbed. 

122.  The  period  commonly  allowed  for  the  drawing  of  a  blis- 


48  GENERAL    OBSERVATIONS. 

ter  is  twelve  hours;  and,  as  a  general  rule,  it  is  sufficient.  But 
as  there  are  many  deviations  from  this  rule,  it  will  be  well  to 
notice  them.  These  departures  from  the  general  law,  are  found 
to  consist  in,  1st,  the  anticipation  of  the  period  of  twelve  hours; 
as  in  children,  and  with  skins  of  peculiar  susceptibilities.  With 
the  first,  under  common  circumstances,  the  blister  is  frequently 
found  to  have  performed  its  duty  in  eight  hours;  and  very  often 
in  six.  It  should,  therefore,  always  be  examined  at  these  pe- 
riods, and  dressed,  if  sufficiently  drawn;*  if  not,  it  must  be 
suffered  to  remain,  until  this  take  place.  With  the  second, 
the  same  rule  should  be  observed  ;  and  we  are  directed  to  the 
belief  that  it  has  drawn,  in  the  adult,  by  the  peculiar  burning 
sensations,  he  may  complain  of.  It  may  be  remarked,  as  a  gene- 
ral rule,  that  children,  (contrary  to  what  we  would  suppose,)  suf- 
fer much  less  than  the  adult,  from  the  action  of  cantharides. 

123.  2d.   The  period  of  twelve  hours  is  sometimes  exceeded; 
owing,  first,  to  the  plaster  not  being  well  applied ;  that  is,  to  its 
being  bound  either  too  tightly,  or  too  loosely.   This  is  no  unusual 
fault  of  a  nurse,  where  the  bandage  is  used  instead  of  the  sticking 
plaster.   If  it  be  bound  negligently,  it  soon  loses  its  contact  with 
the  skin ;  and,  consequently,  cannot  act  upon  a  part  it  does  not 
touch;  if  bound  too  strictly,  the  effusion  of  serum  between  the 
true  and  false  skin,  cannot  take  place ;  for  the  latter  cannot  sepa- 
rate from  the  former,  owing  to  the  mechanical  force  of  the  ban- 
dage, being  too  great.     A  well-skilled  nurse  is  aware  of  this ; 
and  will  bind  the  plaster  only  tight  enough  to  secure  its  contact 
with  the  surface  over  which  it  is  placed. 

124.  Or  it  may  proceed  from  an  exhaustion  of  the  excitability  of 
the  skin  itself,  as  intimated  above.     This  is  no  uncommon  condi- 
tion of  the  skin  in  fevers,'  that  are  disposed  to  terminate  speedily 
in  death;  as  is  witnessed  in  the  yellow  fever,  or  in  high  grades 
of  bilious  fevers.     It  also  takes  place  when  fever  is  long  pro- 
tracted; especially,  where  the  nervous  energy  is  much  impaired. 
And  it  also  happens  from  a  rare,  though  not  without  example, 
indifference,  or  want  of  susceptibility,  to  the  action  of  cantha- 
rides. t   In  either  of  these  cases,  the  cause  should  be  sought  for, 
and  removed  if  possible.     In  the  first  case,  the  remedy  is  as  easy, 
as  it  is  obvious ;  in  the  second,  an  attempt  should  be  made  to  re- 

•  It  is  found  every  way  sufficient  for  the  intended  purpose,  that  if  inflamma- 
tion be  excited,  the  process  to  effusion  will  go  on,  if  the  part  be  dressed  with 
the  yellow  basilicon. 

f  We  once  attended  a  young  lady,  on  whose  skin  we  were  very  desirous  of 
exciting  vesication;  we  tried,  for  this  purpose,  every  form  of  blistering  ointment 
or  plasters  we  could  devise;  we  permitted  them  to  remain  upon  the  part  forty- 
eight  hours  at  a  time;  we  excited  redness  and  irritation,  by  the  spirit  of  tur- 
pentine, or  by  mustard,  and  then  applied  cantharides,  but  all  to  no  purpose; 
vesication  could  not  be  produced.  This  was  not  the  result  of  a  single  trial;  for 
we  persevered  in  our  endeavours,  altering  the  combination  of  the  cantharides, 
and  the  preparation  of  the  skin,  every  day  or  two,  for  a  fortnight. 


GENERAL    OBSERVATIONS.  49 

store,  or  to  create  in  the  part,  a  brisker  circulation,  or  an  im- 
proved state  of  sensibility,  by  frictions,  with  the  substances 
named  above ;  in  the  third,  there  is  no  remedy  that  we  know 
of;  we  can  only  substitute  the  pure  ammoniated  water,  spirit  of 
turpentine,  mustard,  or  Cayenne  pepper. 

125.  Many  nurses  are  in  the  habit  of  placing  a  piece  of  gauze, 
or  very  fine  muslin,  between  the  blister  and  the  skin.     We  have 
never  perceived  the  advantage  of  this  plan,  though  there  is  no- 
thing objectionable  in  it,  provided  the  interposing  substance  be 
sufficiently  thin,  and  the  surface  of  the  plaster  sufficiently  moist, 
to  permit  the  cantharides  to  come  in  contact  with  the  skin.  The 
reason  assigned  for  this  practice,  is,  that  it  prevents  strangury ; 
but  this  is  certainly  a  mistake. 

126.  It  will  be  well  to  remark,  that  in  fevers,  without  any 
apparent  local  inflammation,  the  good  effects  of  blisters,  arise 
more  from  their  effect  upon  the  nervous,  than  upon  the  san- 
guiferous  system;  consequently,  that  their  peculiar  irritation 
is    more  valuable    than  the  discharge  they  produce.     It  will, 
therefore,  happen,  occasionally,  that  we  desire  only  the  inflam- 
mation they  may  excite ;  as  in  cases  of  great  debility,  or  of  pe- 
riodical or  local  pain.     To  insure  this,  the  blister  must  be  exa- 
mined from  time  to  time;  and  removed,  as  soon  as  the  skin  is  well 
reddened.    In  the  first  case,  it  should  be  tightly  bandaged,  when 
the  part  or  parts,  are  either  the  upper  or  lower  extremities,  which 
will  spare  the  debility  arising  from  the  discharge. 

127.  It  may  also  be  important  to  remark,  that  where  blisters 
excite  so  much  local  inflammation  and  irritation  before  the  usual 
period  for  their  drawing  as  to  render  it  desirable  to  interrupt 
them,  that  the  plaster  may  be  removed  as  soon  as  this  condition 
of  the  skin  is  well  established ;  and  that  the  effusion  of  serum  may 
be  insured  by  dressing  them  with  basilicon  ointment,  or  even  by 
the  application  of  a  soft  bread  and  milk  poultice. 

128.  When  blistering  is  prescribed  for  the  legs,  it  must  be 
understood,  that  it  is  the  inner  sides  of  the  calves  that  are  meant. 
Blisters  intended  for  any  part  of  the  extremities,  should  always 
be  longer  than  broad;  and  the  length  of  the  blister,  made  to  cor- 
respond with  the  length  of  the  limb,  when  applied.     When  the 
thighs  are  named,  the  central  portion  of  their  inner  surface  is  to 
be  considered  the  spots.     When  the  arms  are  designated,  the 
inner  parts,  extending  from  below  the  flexure  of  the  elbow  joint, 
to  a  sufficient  distance  above  the  hand,  are  the  places  intended 
to  be  blistered.     By  this  arrangement  the  pulse  can  be  com- 
manded. 

129.  When  ordered  for  the  chest,  the  place  will  be  indicated 
by  the  seat  of  pain,  when  local  affections  are  present — when  the 
chest  generally  is  involved,  the  anterior  portion  of  the  thorax  is 

7 


50  GENERAL    OBSERVATIONS. 

the  place.     The  extent  of  surface  to  be  occupied  by  the  blister, 
will  depend  upon  the  extent  and  force  of  the  disease. 

130.  When  a  blister  is  designed  for  the  neck,  all  that  portion 
of  its  back  part,  from  an  inch,  or  little  more  sometimes  below 
the  hair,  to  nearly  the  lower  extremities  of  the  scapulae  or  shoul- 
der-blades, is  the  part  intended.     When  for  the  ears,  the  hinder 
and  inferior  portion  of  them  are  to  be  understood.     When  for 
the  region  of  the  stomach;  all  the  space  below  the  extremity  of 
the  sternum  or  breast  bone,  (but  inclining  to  the  left  side,)  to 
near  the  umbilicus  or  navel  is  the  part.  When  for  the  abdomen, 
nearly  the  whole  of  the  surface ;  or  in  confined  local  affections, 
only  a  portion  of  it  is  to  be  understood.    When  for  the  temples, 
the  space  immediately  posterior  to  the  termination  of  the  eye- 
brows are  to  be  selected. 

131.  The  shape  of  blisters  vary,  as  much  as  their  size;  the 
latter  will  always  be  determined  by  the  size  and  age  of  the  pa- 
tient; comparatively  small  in  very  young  children;  larger  in 
those  more  advanced,  and  so  on  ;  the  former  must  in  some  mea- 
sure be  determined  by  the  part  designed  for  their  action. 

132.  As  it  is  important  that  some  general  rule  should  be  fol- 
lowed, we  will  lay  down  the  following  measurements  as  guides 
for  the  size  of  blisters;  remarking,  however,  that  a  large  blister 
gives  scarcely  any  more  pain  than  a  small  one,  but  is  oftentimes 
more  efficacious. 

133.  For  the  legs  or  thig'ns,  from  7  to  8  inches  long — from  3 
to  3i  broad. 

134.  For  the  back,  from  7  to  8  inches  long — from  4  to  4J 
broad. 

135.  For  portions  of  the  chest,  from  7  to  8  inches  long — from 
6  to  7  broad. 

136.  For  the  thorax,  from  8  to  9  inches  long — from  7  to  8 
broad. 

137.  For  the  stomach,  from  8  to  9  inches  long — from  6  to  7 
broad.     For  the  stomach,  the  greatest  measurement  must  be 
placed  from  side  to  side. 

138.  For  the  abdomen,  from  10  to  11  inches  long — from  8  to 
10  broad,  if  the  whole  is  to  be  covered ;  of  proportionably  less 
dimensions  if  the  application  is  to  be  partial. 

139.  For  the  ears,  the  size  cannot  well  be  defined,  as  their 
shape  is  peculiar. 

140.  For  the  temples,  from  an  inch,  to  an  inch  and  an  half  in 
diameter  ;  these  are  generally  made  circular. 

141.  These  proportions,  are  the  sizes  for  adults — but  must 
be  reduced  for  younger  people,  or  small  children.   As  the  shapes 
of  blisters  differ,  we  shall  give  drawings  of  them,  (see  Plate  I.) 
which  will  remove  every  difficulty. 


GENERAL    OBSERVATIONS.  51  > 

142.  Dressing  of  the  blister  after  it  has  drawn,  forms  another 
of  the  duties  of  the  nurse;  the  saving  of  pain,  or  other  inconve- 
nience from  the  operation  of  a  blister  will  very  much  depend 
upon  the  skill  and  dexterity  of  the  dresser.  But  before  this  ope- 
ration is  proceeded  upon,  every  thing  necessary  to  the  purpose 
should  be  in  complete  readiness.  The  plasters  should  be  spread; 
the  bandages  ready;  a  pair  of  well-cutting,  sharp-pointed  scissors 
should  be  provided,  as  well  as  a  quantity  of  soft  linen  rags. 

143.  Every  vesicle  upon  the  blistered  surface  should  be  care- 
fully snipped  with  the  points  of  the  scissors,  unless  they  are  very 
small  and  numerous;  if  this  be  the  case,  let  only  the  larger  be 
opened,  as  the  small  ones  will  most  probably  increase  in  size  by 
the  next  dressing,  and  will  then  give  less  trouble.     The  skin 
should  never  be  removed  from  the  surface  of  the  blistered  part 
in  acute  diseases,  however  desirable  it  may  be  to  keep  up  a  dis- 
charge for  a  short  time ;  for  the  irritation  and  pain  which  this 
creates,  is  but  ill  compensated  for,  by  the  increase  or  continu- 
ance, of  the  discharge  it  may  excite — it  is  much  better  to  reap* 
ply  the  blister  for  this  purpose  immediately  after  the  part  has 
healed,  than  to  remove  the  cuticle. 

144.  A  blister  should  never,  or  extremely  rarely,  be  washed, 
though  it  is  a  very  frequent  practice  among  nurses.     It  is  very 
apt  to  produce  chilliness ;  it  exposes  the  denuded  part  to  the  air 
too  long;  it  is  fatiguing  to  the  patient;  it  is  always  a  tedious  pro- 
cess; and  above  all,  it  never  does  good.     At  the  first  dressings, 
the  professed  object,  is  the  removal  of  any  particles  of  the  flies 
that  may  adhere  to  the  surface;  but  if  there  do  remain  some  few, 
they  are  almost  certain  to  be  attached  to  the  dead  skin,  to  which 
they  can  do  no  harm,  and  will  be  removed  at  the  subsequent 
dressings.  If  the  blister  has  suppurated,  the  excuse  is  to  remove 
the  matter  from  it;  than  which  there  can  be  no  worse  practice; 
as  by  the  operation  of  washing,  the  new  and  tender  granulations 
which  this  matter  is  designed  to  protect,  will  be  removed,  and 
the  place  kept  an  open  sore  much  longer  than  is  desirable. 

145.  The  dressings  for  blisters,  will  consist  of  either  stimu- 
lating or  soothing  applications,  as  it  may  be  the  object  of  the 
prescriber.    If  it  be  desirable  to  keep  up  a  discharge,  the  surface 
may  be  dressed  with  the  basilicon  ointment — if  this  be  not  in  view, 
simple  cerate  is  to  be  used.*     Either  of  these  is  to  be  thinly\ 

*  Wilted  cabbage  leaves  are  the  most  common  dressings  out  of  large  cities — 
but  they  should  never  be  employed,  as  they  quickly  become  extremely  of- 
fensive and  annoy  the  patient  very  much — we  have  known  fainting  to  be  pro- 
duced by  a  dressing  of  cabbage  leaves. 

f  A  great  error  is  generally  committed  in  spreading  all  plasters  for  sores;  it 
is  supposed  the  thicker  the  better.  Much  inconvenience  is  created  by  this,  as 
a  large  proportion  of  the  plaster  is  sure  to  adhere  to  the  sore  surface,  from 
which  it  is  detached  with  much  difficulty. 


52  GENERAL    OBSERVATIONS. 

spread  upon  soft,  fine  linen  rags,  and  repeated  twice  in  the 
twenty-four  hours ;  or  only  once  if  the  discharge  be  small. 
It  is  always  best  to  have  plasters  or  dressings,  cut  into  several 
pieces,  when  the  surface  of  the  sore  is  considerable,  as  they  will 
set  much  better  than  a  single  piece,  and  not  get  into  folds;  the 
plaster  should  very  little  exceed  in  size  the  surface  of  the  wound. 

146.  Blisters  now  and  then  become  extremely  painful  and  in- 
flamed ;  this  condition  is  generally  best  subdued  by  a  soft  bread 
and  milk  poultice,  in  which  is  melted  a  small  portion  of.  fresh 
hog's  lard,  or  newly-churned  butter,  before  salt  has  been  added. 
Or  linseed  oil  and  lime-water  may  be  tried  if  the  poultice  fail. 
They  also  become  extremely  itchy,  and  thus  prevent  sleep — but 
this  only  takes  place  during  the  healing  process ;  that  which  has 
succeeded  best  with  me  for  this  itching,  is  a  strong  infusion  of 
the  slippery  elm  bark,  or  flaxseed ;  or  very  fresh  hog's  lard  in 
which  some  laudanum  is  incorporated.     The  part  to  be  washed 
with  either  of  the  former  when  the  itching  is  troublesome,  and 
to  be  covered  with  the  last  by  having  a  rag  well  imbued  with  it. 
Strangury  is  another  consequence  of  the  action  of  a  blister;  in 
some  constitutions,  this  almost  always  takes  place.     We  shall 
treat  of  this  affection  in  another  place. 

14.  Of  administering  Injections,  fyc. 

147.  The  value  of  these  remedies  are  only  beginning  to  be 
properly  appreciated  in  this  country.  They  have  had  to  contend 
against  much  prejudice  to  gain  their  present  consideration.     An 
injurious  and  fastidious  delicacy  has  prevented  their  general  em- 
ployment, especially  out  of  our  cities ;  and  it  is  only  within  a 
few  years  even  in  our  cities,  that  they  have  been  looked  upon  as 
prompt  and  efficient  remedial  applications.     They  have  been  re- 
garded as  extreme  means ;  and  by  some,  even  more  so  than  blis- 
ters ;  and  others  will  not  submit  to  them,  however  necessary,  or 
however  certain  their  utility  might  be. 

148.  For  the  good  of  the  afflicted,  we  hope  this  prejudice  will 
soon  wear  away ;  and  that  they  will  be  looked  upon  as  indispen- 
sable medical,  as  well  as  domestic  remedies. 

149.  Much  of  the  objection  to  injections  has  arisen  from  the 
incompleteness  of  the  apparatus  for  their  administration ;  from 
the  mal-adroitness  of  the  operator,  and  from  the  disgusting  ma- 
terials in  many  instances  of  which  they  have  been  composed. 

150.  The  first  of  these  objections  is  now  entirely  removed,  by 
the  improved  method  of  constructing  them;  and  though  this  has 
in  a  small  degree  increased  the  price,  they  are  nevertheless  very 
much  cheaper  in  the  end  than  those  of  common  fabric.     We 
would  therefore  recommend  in  the  most  earnest  terms  the  pur- 


GENERAL    OBSERVATIONS.  53 

chase  of  the  improved  patent  injection  syringe.  They  are  so 
well  constructed  in  all  their  parts,  as  never  to  disappoint  in  their 
operation,  or  scarcely  ever  get  out  of  repair — whereas  with  the 
common  the  reverse  is  constantly  taking  place.  It  would  be  best 
as  a  general  rule  to  procure  the  two  sizes,  though  this  is  not  ab- 
solutely necessary  in  skilful  hands ;  for  we  have  seen  an  injection 
administered  to  a  child  from  a  large  syringe,  with  as  much  ad- 
dress and  certainty,  as  if  it  were  of  the  smaller  size;  for  the  pis- 
ton and  cylinder  are  fitted  so  exactly  to  each  other,  that  an  injec- 
tion of  no  greater  volume  than  a  table-spoonful  can  be  as  certainly 
administered,  as  one  of  larger  size.* 

151.  The  second  objection  to  injections  should  never  exist,  if 
a  professed  nurse  is  to  be  the  operator;  for  it  is  as  much  a  part  of 
her  business  as  any  other  belonging  to  her  art;  and  she  had  as 
well  be  ignorant  of  any  other  important  detail  as  this.   Her  want 
of  cleverness  in  this  particular,  should  have  no  other  excuse, 
than  a  want  of  experience;  and  if  she  lack  this,  she  is  an  impro- 
per nurse,  and  should  only  be  employed  as  a  dernier  resource. 
Besides,  there  is  no  excuse  for  ignorance  upon  this  point;  for  it 
is  the  simplest  of  all  operations;  and  once  having  performed  it, 
it  can  always  be  performed. 

152.  The  third  objection  is  fast  wearing  away;  as  enemata  are 
now  for  the  most  part  made  to  consist  of  but  few,  and  oftentimes 
of  but  very  simple  materials.     Soot,  soft  soap,  fish  brine,  train 
oil,  and  other  disgusting  substances,  are  now  yielding  to  plain 
water  and  salt,  flaxseed  tea,  starch,  &c.  &c.   It  is  now  no  longer 
considered  necessary  to  make  them  very  complicated,  as  was 
sometimes  formerly  done,  and  is  even  now,  in  some  places.  We 
were  informed,  and  by  good  authority,  that  a  European  practi- 
tioner had  an  injection  made  of  no  less  than  two-and-thirty  arti- 
cles; an  half  day  was  nearly  spent  in  collecting  the  ingredients, 
and  it  required  a  preparation  of  several  hours  before  it  could  be 
administered. 

153.  The  importance  of  injections  is  never  more  manifest 
than  in  cases  where  it  is  every  way  important  that  a  sudden  dis- 
charge from  the  bowels  is  necessary;  where  the  stomach  is  too 
irritable  to  retain  any  thing ;  where  it  is  desirable  to  make  an 
impression  upon  the  nervous  system  without  disturbing  the  sto- 
mach ;  where  a  direct  application  is  to  be  made  to  the  affected 
part,  as  in  dysentery  and  diarrhoea;  or  as  near  to  the  part  as  pos- 
sible, as  affections  of  the  uterus,  &c. 

154.  The  purgative  medicines  are  sometimes  most  success- 

*  These  improved  syringes  can  be  procured  at  almost  any  of  our  druggists. 
They  are  now  made  perfectly  well  in  New  York;  and  many  of  our  apothecaries 
keep  them — inquire  for  the  best  New  York  syringes. 


54  GENERAL    OBSERVATIONS. 

fully  administered  in  this  way;  and  the  anodyne  and  antispas- 
modic,  with  great  certainty.  As  a  general  rule,  the  two  last  must 
be  used  in  triple  quantities  by  injection.  Besides  the  qualifica- 
tions enumerated  above,  the  professed  nurse  should  also  be  well 
skilled  in  certain  parts  of  cookery;  especially  such  as  are  proper 
for  the  patient  during  the  continuance  of  the  disease.  We  shall 
in  another  part  of  this  work,  give  recipes  for  some  of  the  more 
important  articles  of  food  and  drink;  for  on  their  proper  mani- 
pulation much  of  the  comfort  of  the  patient  will  depend. 

1 5.  Of  the  Management  of  Convalescence. 

155.  The  management  of  the  patient  after  the  cessation  of 
fever,  or  the  commencement  of,  and  during  convalescence,  is  one 
of  the  most  important  points  in   the  treatment  of  disease ;  yet, 
unfortunately,  it  is  one  that  is  the  most  neglected;  or  to  which, 
the  least  attention  is  given.   A  neglect  of  the  proper  observances 
at  this  time,  has  been  but  too  often  productive  of  the  most  seri- 
ous injuries;  either  by  producing  a  relapse;  or  the  production  of 
a  new  disease.*  And,  first,  of  a 

Relapse. 

156.  The  highly  excitable  condition  in  which  the  system  is 
always  left  after  an  attack  of  any  acute  disease,  renders  it  ex- 
tremely liable  to  its  return  from  very  slight  provocations;  it  is, 
therefore,  of  the  utmost  consequence  to  become  well  acquainted 
with  the  causes  that  may  be  capable  of  this  effect.     These  will 
be  found  to  consist  in  the  administration  of  either  improper  ar- 
ticles of  food,  and  drinks;  or  in  the  too  early,  or  improper  ex- 
posure to  the  weather,  &c. 

157.  The  extreme  anxiety  to  prevent,  or  to  overcome  "de- 
bility," (23)  as  we  have  observed  before,  has  been,  without  the 
slightest  exaggeration,  the  death  of  thousands — upon  this  point, 
we  have  no  mental  reservations;  we  mean  what  we  have  de- 

*  "  If  it  be  right  for  the  physician  to  snatch  from  impending  death  the  pa- 
tient confided  to  his  care;  if  it  be  his  duty  to  be  lavish  of  his  attentions  to  him 
in  the  moment  of  danger;  the  task  that  remains  to  be  fulfilled  during  convales- 
cence, though  less  brilliant  in  appearance,  is  however  not  less  important,  or 
less  difficult.  Like  the  vessel  that  has  escaped  with  much  injury  from  the  vio- 
lence of  a  tempest,  convalescence,  is  but  ill  calculated  to  brave  new  dan- 
gers; it  requires  both  a  skilful  and  judicious  pilot  to  navigate  it  safely  in  the 
midst  of  rocks  which  surrounds  it.  It  is  not  without  reason  that  the  physician 
who  abandons  his  patient  during  this  period,  is  compared  to  a  careless  pilot, 
who  takes  no  care  of  his  vessel,  at  the  moment  he  is  about  to  enter  port." — 
Jlennes'  Considerations  G6ntraks  sur  la  Convalescence. 


GENERAL    OBSERVATIONS.  55 

clared  upon  this  subject  should  be  understood  in  the  most  literal 
sense  of  our  words;  for  nothing  can  exceed  the  sincerity  of  our 
belief  in  what  we  have  advanced.  To  the  want  of  caution  on  the 
part  of  the  nurse;  or  to  the  importunities  and  suggestions  of 
friends;  or  by  people  out  of  the  profession,  or  sometimes  from 
the  waywardness  of  the  patient  himself,  we  may  look  for  the 
cause  of  the  solemn,  and  dreadful  truth,  we  have  just  advanced. 

158.  It  has  ever  struck  us  with  surprise,  that  people  who  are 
altogether  unacquainted  with  the  structure  of  the  human  body, 
or  with  the  laws  which  govern  it,  either  in  a  state  of  health,  or 
more  especially,  when  labouring  under  disease,  should  take  the 
awful  responsibility  upon  themselves  to  direct,  what  is  supposed 
by  them  to  be  proper,  during  the  existence  of  disease,  or  when 
the  system  has  just  struggled  through  it.     They  cannot  have 
weighed  the  extent  of  injury,  that  might  arise  from  their  advice ; 
or  they  would  not  thus  voluntarily  assume  the  responsibility,  of 
either  immediately,  or  remotely,  causing  death,  or  a  lingering 
disease.     Yet,  no  one  out  of  the  profession  can  offer  opinions 
upon  the  state  of  a  patient,  or  suggest  means  for  benefiting  it, 
without  incurring  this  terrible  risk.   (16) 

159.  So  nice  a  point  is  this  sometimes,  that  the  physician  him- 
self does  not  choose  to  act  upon  his  own  individual  judgment; 
on  the  contrary,  he  solicits  the  aid  of  a  brother  practitioner  to 
aid  it,  and  to  divide  responsibility.   Yet,  at  this  very  moment  of 
doubt  and  uncertainty;  where  the  life  of  the  patient  may  depend 
upon  correct  views  being  taken  of  his  situation,  we  find  people 
flocking  to  the  bed-side,  and  fearlessly  directing,  that,  which 
may,  if  their  instructions  be  followed,  cause  death.     This  is  no 
false  picture;  it  has  been  witnessed  by  thousands,  though  unfor- 
tunately, it  has  effected  no  beneficial  change  in  the  sick  room. 

160.  But  strange  to  tell,  there  is  no  one  who  does  not  depre- 
cate this  kind  of  interference  in  the  abstract;  yet  every  body  at 
the  moment  they  have  the  opportunity  to  infringe  it,  flatter 
themselves  that  they  become  exceptions  to  the  rule,  and  that, 
what  they  say  or  do,  cannot  be  otherwise  than  right;  or  at  least, 
that  it  cannot  do  harm.     In  no  other  concern  of  life,  does  the 
same  docility  occur — if  the  distribution  of  property,  or  the  em- 
ployment of  money  become  the  subject  of  advisement,  much  he- 
sitation, and  deliberation  is  exercised  before  the  sought  for,  or 
proffered  advice,  is  followed.    If  a  coat  is  to  be  cut,  or  a  pair  of 
shoes  or  boots  are  to  be  made,  the  qualifications  of  the  recom- 
mended, are  carefully  scanned,  before  they  are  trusted;  but  the 
business  of  sickness,  or  of  health;  or  of  life,  or  of  death;  are  dis- 
missed, with  the  most  frigid  indifference;  and  too  often,  the  ad- 
vice of  one,  totally  incompetent  to  the  task,  is  promptly  adopt- 


56  GENERAL    OBSERVATIONS. 

ed,  to  the  neglect  of  that,  given  by  one,  who  was  every  way 
able  to  direct. 

161.  We  could  wish  that  this  subject  should  receive  more  at- 
tention than  it  has  hitherto  done;  it  every  way  merits  the  most 
profound  attention;  the  public  weal  demands  it;  and  it  is  the 
bounden  duty  of  every  individual  to  act  up  to  the  principles  we 
are  endeavouring  to  establish — namely,  that  all  advice,  and  every 
departure  from  the  directions  of  the  physician,  or  the  general 
rules  established  by  him,  is  replete  with  mischief;  and  involves 
all  who  may  advise,  or  who  may  depart,  in  a  dangerous  enter- 
prise, or  in  an  awful  responsibility.  How  many  orphans,  widows, 
or  desolated  husbands,  have  to  thank  the  officiousness  of  friends, 
for  their  sad  condition — for  to  the  advice,  or  the  interference  of 
those  who  had  neither  right,  nor  talent  to  direct,  may  they  in 
too  many  instances  justly  look,  for  their  misfortunes. 

162.  We  are  willing  however,  to  believe,  that  the  interfer- 
ence complained  of,  does  not  arise  from  any  evil  intention,  or 
any  absolute  design,  to  thwart  the  plans  of  the  medical  attend- 
ant ;  but  at  the  same  time  we  feel,  that  the  plea,  of  "  no  harm 
being  intended,"  is  not  sufficient  to  prevent  mischief  from  fol- 
lowing the  interference;  and,  that  it  is  certainly  altogether  in- 
adequate to  the  repair  of  it,  after  it  has  been  done.   In  such  cases, 
every  body  should  feel,  that  injury  may  arise  from  their  advice, 
or  opinions. 

163.  But  to  return.     We  agree,  with  the  most  inveterate 
"  feeders,"  that  the  ravages  of  disease  should  be  repaired  as 
speedily  as  is  consistent  with  the  safety  of  the  patient ;  and  con- 
sequently, every  way  willing  that  strength  should  be  restored. 
We  only  differ  in  a  most  essential  point,  namely;  in  the  means. 
Those  against  whom   we  are  contending,   suppose   the   more 
promptly  the  restoration  of  strength  is  attempted,  the  better;  to 
effect  this,  they  imagine  that  the  most  nourishing  animal  sub- 
stances and  stimulating  diet  are  required.     While  we  on  the 
other  hand  insist,  that  the  blood-vessels  cannot  well  be  filled  too 
slowly;  and  that  the  nervous  system  cannot  well  be  treated  too 
kindly;  for  neither  will  bear  but  very  little  stimulation  with 
profit,  after  they  have  been  deranged,  and  perhaps  severely  de- 
ranged, by  disease,  and  its  necessary  treatment.     Hence,  the 
necessity  for  some  time,  of  the  most  bland  or  even  vegetable 
diet. 

164.  With  a  view  to  illustrate  this  better,  we  will  very 
briefly  describe  the  condition  of  the  body  after  a  severe  attack 
of  a  febrile,  or  other  acute  disease,  that  the  application  of  stimu- 
lating food  and  drinks  may  be  the  better  comprehended. 

165.  First,  there  must  necessarily  be,  after  illness,  a  great  re- 
duction of  both  the  solids  and  fluids,  of  the  body;  and  conse- 


GENERAL    OBSERVATIONS.  57 

quently,  that  the  first  must  be  left  in  a  state  of  great  weakness; 
and  that  the  vessels  containing  the  latter,  must  be  comparatively 
empty,  as  well  as  weak.  Now,  strength  cannot  be  imparted  to 
the  solids,  but  through  the  medium  of  the  nervous  system,  and 
of  the  vessels  conveying  fluids;  the  nervous  system  and  blood- 
vessels can  only  do  this,  when  their  actions  are  healthily  per- 
formed; and  their  actions  can  only  be  healthily  performed,  when 
they  are  properly  filled,  and  duly  stimulated.  Therefore,  any 
excess  of  stimulation  will,  from  the  increase  of  irritability, 
(which  is  always  consequent  upon  a  sudden  reduction  of  the 
force  of  the  body,)  urge  them  to  inordinate  action.  It  will  there- 
fore follow,  that  over-nutritious  food,  or  too  great  a  quantity  of 
that  which  is  less  so,  will  always  invite  a  return  of  fever  if 
given  too  early  in  convalescence;  hence,  the  frequency  of  re- 
lapses after  a  full  meal. 

166.  If  this  be  true,  it  will  follow  as  a  legitimate  consequence, 
that  strength  cannot  be  imparted  to  the  solids,  while  the  blood- 
vessels and  nervous  system  are  goaded  to  inordinate  action;  or 
to  that  degree  of  action,  which  is  beyond  the  healthy  bound; 
this  condition  will  necessarily  be  followed  by  a  state  of  inertia, 
or  weakness;  and  this  in  the  precise  ratio  of  the  over-action; 
therefore,  instead  of  strength  being  increased  by  this  plan,  it  is 
constantly  found  to  be  diminished.     But  this  is  not  all;  it  too 
frequently  happens  that  fever  is  rekindled,  and  a  complete  re- 
lapse is  established. 

167.  Second.    The  stomach,  like  every  other  portion  of  the 
body  suffers  a  loss  of  vigour  from  illness;   consequently,  its  di- 
gestive powers  are  diminished;  therefore,  when  food  of  too  nu- 
tritive a  kind  is  offered  to  it,  one  of  two  evils  must  necessarily 
arise.     First,  that  the  stomach,  from  the  reduction  of  its  powers, 
will  not  be  able  to  convert  it  into  nourishment;  and  if  it  .do  not, 
it  remains  an  undigested  mass  within  it,  which  sooner  or  later 
must,  and  will  be  disposed  of,  either  by  vomiting,  or  by  diar- 
rhea; neither  of  which  will  contribute  towards  the  strength  of 
the  patient.     Or,  what  virtually  amounts  to  the  same  thing,  if 
too  much  of  a  substance  less  nutritive  be  given,  the  same  conse- 
quences are  sure  to  follow.     On  the  other  hand;  if  the  stomach 
have  been  capable  of  mastering  the  whole  of  the  mass  offered  to 
it,  too  much  nourishment  is  formed;  and  will  be  introduced  too 
suddenly  into  the  weakened^irritable,  and  the  easily  distensible 
blood-vessels;  in  consequence  of  which,  fever  is  for  the  most 
part  rekindled. 

168.  Equally,  but  more  suddenly  injurious,  is  the  exhibition 
of  stimulating  drinks  of  every  kind;  they  excite  to  inordinate 
action,  both  the  nervous  and  sanguiferous  systems;  and  too  cer- 
tainly reproduce  the  disease  from  which  the  system  has  just  been 

8 


58  GENERAL    OBSERVATIONS. 

freed.  On  account  of  the  certainty  and  suddenness  of  their  in- 
fluence, they  are  more  decidedly  injurious  than  animal  food;  and 
therefore,  should  be  still  more  cautiously  withheld. 

169.  Third.    Illnesses  of  the  acute  kind,  are  constantly  fol- 
lowed  by  a  weakened  tone  of  the  whole  circulating  system; 
hence,  we  find  a  smaller,  but  a  quicker  pulse;  the  quickness  ap- 
pearing to  be  a  constant  attendant  upon  the  diminution  of  power. 
Hence,  one  of  the  surest  presages  of  returing  power  is,  the 
diminution  of  the  frequency  of  the  pulse,  and  an  increase  of  vo- 
lume in  the  artery.    From  this  it  would  appear,  that  an  increase 
of  the  circulation  is  not  favourable  to  the  state  of  convalescence; 
for  strength  is  not  acquired,  during  its  continuance.     Animal 
food,  or  other  stimulants,  when  improperly  exhibited,  increase 
the  circulation;  therefore  animal  food  and  other  stimulants  must 
be  injurious;  because,  they  increase  the  rapidity  of  the  circula- 
tion. 

170.  It  is  true,  that  the  too  early  use  of  animal  substances,  or 
of  stimulating  drinks,  do  not  always  occasion  a  relapse;  but 
should   they  not  do  this,  they  are  very  often   far  from  being 
harmless;  for  effusions  in  various  parts  of  the  cellular  membrane 
are  very  sure  to  follow,  if  a  genuine  dropsy  be  not  the  conse- 
quence. 

171.  This  is  not  the  proper  place  to  explain  at  length,  the 
cause  of  this  swelling;  we  shall  merely  observe,  that  it  is  an  al- 
most constant  law  of  the  sanguiferous  system,  to  unload  itself 
when  oppressed  by  too  great  a  quantity  of  fluid,  by  pouring  out 
a  part,  into  the  interstices  of  the  cellular  membrane  and  serous 
cavities.   This  is  witnessed  in  the  drawing  of  blisters;  in  dropsies 
of  the  brain,  chest,  &c.  &c.     Now  the  same  thing  takes  place, 
when  the  blood-vessels  are  suddenly  over-charged  from  any 
cause;  and  it  is  perfectly  familiar  to  every  observing  person,  that 
it  happens  to  those  who  have  been  too  quickly  put  upon  an  over- 
nutritious  or  stimulating  diet,  when  recovering  from  illness. 

172.  We  are  not  ignorant,  that  it  is  altogether  contrary  to 
common  opinion,  that  dropsy  or  dropsical  swellings,  can  be  pro- 
duced by  any  other  cause  than  weakness — hence,  we  hear  of 
people  being  purged,  dieted,  or  bled,  into  a  dropsy;  but  never 
that  they  have  been  fed  into  one.     Yet  the  latter  is  a  solemn 
truth;  as  the  following  little  history  will  clearly  prove. 

173.  A  most  amiable  and  worthy  young  gentleman,  a  parti- 
cular friend  of  the  author's,  had  been  most  severely  attacked 
with  pleurisy,  for  the  cure  of  which  he  had  been  pretty  exten- 
sively bled,  and  was  of  course  much  reduced  in  strength.     So 
soon  as  his  fever  had  left  him,  he  was  permitted  to  sit  up;  and 
as  soon  as  he  was  able,  he  was  permitted  to  walk  about  his  cham- 
ber; so  far  so  good.     His  appetite  was  feeble;  and  he  remained 


GENERAL    OBSERVATIONS.  59 

satisfied  with  the  very  moderate  diet,  that  had  been  prescribed 
for  him  during  the, continuance  of  the  disease.  He  was  now 
rapidly  recovering  strength;  and  was  thought  by  his  medical  at- 
tendant to  be  in  a  state  of  happy  convalescence.  At  this  time, 
his  kind  and  attentive  physician,  was  under  the  necessity  of 
leaving  the  city  for  some  days,  and  as  he  was  gaining  strength, 
and  flesh,  as  fast  as  was,  (rationally,)  desirable,  he  was  left  to  the 
care  of  his  nurse,  with  directions  that  his  diet  should  be  a  little 
more  generous. 

174.  The  nurse  thought,  that  the  patient  now  only  required 
the  cook,  as  the  doctor  had  taken  his  leave;  and  to  prove  her- 
self faithful  to  her  own  opinions,  commenced  forthwith,  with  a 
well-seasoned  beef-steak,  and  a  glass  of  porter.     At  this  time 
the  author  called  on  his  friend  to  offer  him  his  congratulations; 
etiquette  having  forbad  before,  any  thing  but  inquiries  at  the 
door.    We  found  him  in  high  spirits;  as  the  visit  was  very  soon 
after  the  meal  of  beef-steak,  and  porter;  he  declared  himself 
never  better,  and  asked  of  the  author,  if  he  did  not  think,  he 
would  soon  be  perfectly  restored — the  only  reply  was,  that  he 
would  do  very  well,  if  he  took  care  not  to  eat  himself  into  a 
dropsy;  at  which  he  laughed  very  heartily;  at  the  same  time  de- 
claring, it  was  for  the  first  time  in  his  life,  that  he  had  heard, 
that  a  man  could  eat  himself  into  a  dropsy.     The  caution  was 
repeated;  but  it  could  not  be  enforced,  for  he  was  not  our  pa- 
tient. 

175.  Soon  after  this  he  left  the  city  for  the  benefit  of  country 
air;  and  in  about  three  months  returned  to  it,  with  confirmed 
dropsies  of  the  abdomen,  and  chest,  of  which  he  soon  after  died. 
He  informed  us  that  he  pursued  the  full  diet,  until  he  was 
brought  to  the  state  in  which  he  was  now  found;  and  that  after 
dropsy  showed  itself,  it  was  thought  proper  to  persevere  in  it; 
as  dropsy  only  could  arise  from  debility.    To  understand  how 
great  this  error  is,  see  Chapter  on  Dropsy. 

176.  To  those  who  are  disposed  to  listen,  this  case  speaks  vo- 
lumes; and  if  practically  acted  upon,  will  be  most  useful.     It 
clearly  shows  the  certain,  and  terrible  consequences  of  impro- 
prieties in  diet,  after  the  system  has  been  reduced  by  an  acute 
disease,  and  the  active  treatment  essential  to  its  removal.    With 
these  preliminary  observations  in  view,  we  will  lay  down  a  few 
rules  in  conformity  with  them,  for  the  government  of  the  nurse. 

177.  First.  That  no  animal  substance,  in  any  shape  or  form, 
should  be  given  during  the  continuance  of  fever;  nor  very  im- 
mediately after  its  cessation,  lest  it  be  invited  to  return  by  the 
over-stimulating  quality  of  this  substance. 

178.  Secondly.  That  after  the  cessation  of  fever  of  any  deno- 
mination, a  sufficient  time  should  be  given  for  the  system  to  re- 


60  GENERAL    OBSERVATIONS. 

cover  from  the  habit,  if  we  may  so  express  ourselves,  of  forming 
it,  (before  any  alteration  be  made  in  the  diet.)  For  if  this  be 
not  heeded,  fever  will  almost  constantly  be  reproduced,  even  by 
a  small  change  in  the  articles  of  food. 

179.  Thirdly.    Such  fevers  as  have  manifested  a  periodical 
movement,  should  be  particularly  attended  to;  because,  there  is 
no  certainty  that  there  will  not  be  a  return  upon  the  next  pa- 
roxysmal day;  though  it  may  have  passed  one  period.     Thus,  a 
quotidian,  after  the  paroxysms  has  stopped,  three  consecutive 
days  at  least  should  be  permitted  to  pass,  lest  it  may  return; — 
either  from  the  disease  not  having  been  subdued,  or  from  the 
alteration  produced  in  the  system  by  the  quality  of  the  food.    In 
the  tertian,  two  paroxysmal  days  should  be  allowed  to  pass.     In 
the  quartan,  one  will  be  generally  sufficient. 

180.  Fourthly.  When,  agreeably  to  these  rules,  a  change  in 
the  food  is  decided  upon,  the  choice  at  first  should  be  of  such  ar- 
ticles as  possess  the  least  possible  stimulus,  of  their  class — or  in 
other  words,  the  transition  from  a  mild  vegetable,  to  an  animal 
diet,  should  be  as  slight  as  the  nature  of  things  will  permit.   Thus, 
weak  chicken  water:  weak  beef,  or  veal  tea;  or  the  diluted  juice 
of  oysters,  should  first  be  resorted  to. 

181.  Fifthly.  That  the  above  enumerated  articles  should  be 
given  in  small  quantities  at  a  time,  and  repeated  at  stated  inter- 
vals, both  by  day  and  night,  if  the  patient  be  very  feeble,  pro- 
vided, it  will  not  interrupt  important  sleep.     And  care  should 
be  taken  in  highly  excitable  systems,  to  withhold,  for  a  few 
days,  animal  sustenance,  during  the  period  the  fever  was  wont 
to  appear  in  its  greatest  force.* 

182.  Sixthly.  That  the  patient  should  be  confined,  for  at  least 
three  days,  to  the  above  prescribed  articles,  before  the  power  of 
the  food  be  increased;  and  when  this  is  determined   on,  such 
substances  should    be    selected,  as  will  very  little    exceed    in 
strength  those  already  exhibited.     These  will  consist  of  the  soft 
ends  of  five  or  six  oysters;  a  soft  boiled  egg:  a  small   piece  of 
boiled  fish,  or  the  cold  custard.  (See  Art.  Cold  Custard.) 

183.  Seventhly.    After  this  plan  has  been  persisted  in  for 
three  or  four  days,  the  patient  may  be  indulged  in  a  small  piece 
of  boiled  mutton;  the  breast  of  partridge  or  pheasant;  turkey,  or 

*  By  this  we  would  wish  to  be  understood,  the  time  of  day,  at  which  the 
exacerbation  was  wont  to  take  place.  The  reason  for  this  caution  is,  that  not- 
withstanding the  fever  has  ceased  to  appear,  yet  there  is  a  disposition  in  the 
system  to  be  more  readily  affected  by  stimuli  at  the  time  of  day  at  which  the 
fever  was  accustomed  to  be  the  highest;  and  this  condition  will  remain  for  se- 
veral days  sometimes.  On  this  account,  it  is  always  best  to  give  at  these  pe- 
riods, the  mild  vegetable  substances,  the  patient  has  been  in  the  use  of,  dur- 
ing the  existence  of  the  disease,  instead  of  the  more  stimulating  articles,  lately 
employed. 


GENERAL    OBSERVATIONS.  61 

chicken.  And  after  as  many  more,  he  may  be  allowed,  a  small 
piece  of  rare  done  beef  or  venison  steak ;  mutton  chop,  or  sweet 
bread.  At  this  latter  period,  a  tumbler  of  ale,  or  porter  and  wa- 
ter, may  be  given  at  noon,  with  the  meal  intended  for  this  hour; 
provided  no  circumstance  exists  to  render  this  substance  impro- 
per; such  as,  its  causing  head-ache;  flatulency;  or  sourness  of 
stomach.  Many  are  of  opinion,  that  Port  wine  is  always  ad- 
missible after  the  cessation  of  fever;  especially  after  those  of  an 
intermittent  kind;  this  is  one  of  the  many  vulgar  errors  that  the 
physician  has  to  contend  against;  and  the  sooner  it  is  destroyed, 
the  better.  We  have  never  seen  the  slightest  good  follow  its  use; 
though  we  have  often  known  much  mischief  to  be  the  conse- 
quence of  its  employment* 

184.  Eighthly.   During  the  whole  period  of  convalescence, 
the  bowels  should  be  most  strictly  attended  to — one  evacuation 
daily  is  absolutely  necessary;  if  this  does  not  take  place  sponta- 
neously, it  must  be  procured   by  a  simple  rhubarb  pill  taken 
every  night  at  bed  time,  (see  Art.  Rhubarb  pills,  at  the  end  of 
the  Vol.)    But  purging  must  be  avoided  most  carefully. 

185.  Ninthly.  The  quantity  of  exercise  should  also  be  very 
carefully  regulated ;  for  there  is  no  opinion  more  general,  than, 
that  the  patient  should  take  as  much  as  he  can  possibly  endure ; 
than  which,  there  cannot  well  be  a  more  dangerous  error.     It  is 
admitted,  that  a  well-regulated  plan  of  exercise  will  be  highly 
serviceable,  when  the  strength  of  the  patient  is  such  as  to  render 
it  profitable ;  that  is,  when  he  can  perform  a  certain  quantity  of 
motion,  without  producing  fatigue.     And  the  effect  of  motion, 
must  always  be  the  guide  for  both  the  repetition,  and  the  degree 
to  which  it  may  be  carried  ;  for,  if  very  little  exhaust,  that  very 
little  is  too  much.     Therefore,  when  it  is  again   attempted,  it 
should  be  less  than  that,  which  had  previously  been  followed  by 
fatigue.     This  degree  should  be  persisted  in,  until  the  muscles 
acquire  sufficient  tone  to  bear  more ;  and   when  an  additional 
quantity  can  be  supported  well,  an  increase  should  be  admitted; 
and  so  on,  until  strength  is  established.     By  observing  these 
rules,  we  are  certain,  that  vigour,  will  be  much  more  certainly, 

*  By  this  declaration,  we  wish  to  convey  the  idea,  that  in  our  opinion,  there 
is  no  particular  virtue  in  Port  wine,  that  would  remove  it  from  the  ban  under 
which  we  have  put  the  whole  class  of  diffusible  stimuli  at  too  early  a  period 
of  convalescence.  And  that  when  it  has  been  employed  too  early,  under  the 
impression  that  it  possessed  some  specific  quality  favourable  to  that  particu- 
lar, and  highly  excitable  condition  of  the  system,  that  we  have  witnessed  much 
injury  arise  from  its  use.  We  do  not  wish  to  withhold  this  article  from  the  in- 
valid, at  the  time  wine  of  any  denomination  might  be  proper;  for  if  he  prefer 
it,  he  should  be  indulged  in  his  choice.  It  may  not  be  amiss,  however,  to  re- 
mark, that  there  is  no  wine  that  comes  to  this,  or  any  other  market,  that  is  so 
uniformly  adulterated,  or  so  rarely  found  good. 


62  GENERAL    OBSERVATIONS. 

and  speedily  acquired,  than  if  the  contrary  plan  be  pursued.  The 
exercise  here  alluded  to,  refers  entirely  to  that,  which  can,  and 
must  be  performed,  within  doors.  For  the  invalid  must  com- 
mence with  exercise  in  the  house,  before  it  will  be  eligible  to 
exercise  out  of  doors. 

186.  Tenthly.  As  it  is  every  way  important,  that  the  patient 
should  have  the  benefit  of  fresh  air  as  early  as  possible,  we  will 
attempt  to  lay  down  a  few  rules  for  his  indulging  in  it. 

187.  1.   The  patient  should  never  be  allowed  to  exercise  out 
of  doors,  before  he  is  capable  of  walking  about  his  floor  for  some 
minutes  without  any  great  fatigue;  or  in  other  words,  until  he 
has  complied  with  the  regulations  of  direction  ninth.     It  is  al- 
ways well  to  destroy,  as  early  and  as  effectually  as  possible, 
every  unpleasant  association  connected  with  the  suffering  of  the 
patient;  therefore,  as  soon  as  he  is  able,  it  is  proper  to  remove 
him  during  the  day  into  another  room;  while  the  one  he  was 
confined  in  is  refreshed  by  cleansing  and  the  admission  of  fresh 
air.     Even  the  vials,  pill-boxes,  &c.  which  have  accumulated 
during  illness,  should  be  removed  from  the  sick  room,  the  mo- 
ment there  is  no  further  use  for  them  ;  and  the  whole  appearance 
of  the  room  should  be  changed  as  much  as  practicable,  that  the 
patient  may  not  have  gloomy,  or  painful  associations,  connected 
with  the  things  with  which  he  had  become  so  familiar  during  his 
illness. 

188.  2.  The  weather  should  always  regulate  every  attempt 
at  exercise  without  doors;  for  if  it  be  bad,  that  is,  windy,  cold, 
very  hot,  extremely  wet,  or  very  dusty,  the  invalid  should  not 
venture  abroad  during  the  continuance  of  either  of  these  states  of 
the  atmosphere  or  roads. 

189.  3.  When  strength  will  justify  exercise  abroad,  it  should 
always,  when  practicable,  be  first  performed  in  a  close  carriage ; 
regulating  its  closeness,  by  circumstances,  that  will  at  once  pre- 
sent themselves. 

190.  4.  It  should  constantly  be  borne  in  mind,  that  when 
exercise  is  carried  to  fatigue,  that  injury,  instead  of  benefit,  is 
constantly  the  consequence — and  this  is  almost  sure  to  happen 
in  the  first  attempts.     This  arises  in  most  instances,  from  its  not 
occurring  to  those  who  may  have  charge  of  the  invalid,  that  he 
has  to  return  over  every  inch  of  ground  that  he  has  already  pass- 
ed, which  in  the  outward  progress  was  not  thought  of.  We  have 
seen  from  this  cause  many  instances  of  great  suffering  from  ex- 
haustion; and  thus,  every  advantage  which  well-regulated  exer- 
cise had  promised,  has  been  entirely  defeated. 

191.  5.  The  invalid  should,  upon  every  occasion  of  this  kind, 
be  carefully  provided  with  additional  covering;  lest,  in  our  fitful 
climate,  a  sudden  transition,  from  a  higher  to  a  lower  tempera- 


GENERAL   OBSERVATIONS.  63 

ture  take  place  during  his  absence,  and  thus  be  exposed  to  the 
risk  of  taking  cold. 

192.  6.  As  soon  as  renovated  strength  will  permit,  the  patient 
should,  in  properly  selected  weather,use  the  best  of  all  exercises — 
namely,  walking.     By  this,  every  muscle  of  the  body,  is  made 
to  bear  its  proportion  of  expenditure;  and  at  the  same  time  re- 
ceive, its  proper  quantum  of  benefit.     This  kind  of  exercise  is 
particularly  valuable  to  those,  who  have  tardy  bowels;  (a  condi- 
tion by  the  by,  common  to  almost  all,  who  are  recovering  from 
acute  diseases,)  for  the  employment  of  the  lower  limbs,  and 
of  the  abdominal  muscles,  gives  the  intestines  a  more  certain, 
and  uniform  action,  by  their  mechanical  pressure  upon  them. 

193.  7.   The  utmost  vigilance  should  be  exercised,  that  the 
invalid  does  not  expose  himself  to  currents  of  cold,  or  damp  air; 
and  that  he  be  made  to  avoid  sitting,  or  going  into  damp  places, 
especially  if  his  skin  be  disposed  to  moisture,  from,  either  re- 
maining weakness,  or  from  its  having  been  excited  by  exercise. 
He  should  not  take  a  full  draught,  of  the  most  grateful  of  all 
beverages,  to  the  convalescent,  namely,  cold  water. 

194.  8.  A  convalescent  should  pay  strict  attention  to  the  fol- 
lowing important,  though  apparently  insignificant  rules  of  con- 
duct during,  and  after  eating;  first,  not  to  take  but  little  fluid  of 
any  kind  into  his  stomach  during  his  meals,  nor  immediately 
after ;  second,  occupy  as  much  time  as  can  reasonably  be  spent, 
in  the  mastication  of  his  food ;  third,  not  to  exercise  too  soon 
after  any  repast;  but  especially  after  dinner;  and  fourth,  not  to 
sleep  either  too  soon  or  too  long,  after  either  dinner,  or  his  after- 
noon meal;  fifth,  to  eat  no  supper. 

195.  9.  If  the  patient  be  recovering  from  illness  in  the  fall  of 
the  year,  or  in  early  spring,  let  him  wear  flannel  next  to  his  skin, 
if  he  has  not  already  been  in  the  habit  of  doing  so;  but  especially, 
let  him  protect  his  lower  extremities  well,  by  warm  stockings, 
and  sufficiently  thick  boots  or  shoes — the  former  however,  are 
always  to  be  considered  preferable  to  the  latter;  as  they  more 
effectively  protect  from  cold,  a  very  sensitive  part  of  the  body; 
namely,  the  ankles. 

196.  10.  Let  him  avoid  with  the  greatest  care,  the  several 
substances,  almost  constantly  presented  to  the  invalid,  because 
they  are  thought  to  be  highly  nourishing,  and  most  easy  of  di- 
gestion ;  such  as  calve's  feet,  hartshorn,  chicken  and  beef  jellies.* 

*  Dr.  Paris  observes  upon  this  subject,  that  jellies  and  other  gelatinous  sub- 
stances, though  containing  the  elements  of  nourishment  in  the  highest  degree 
of  concentration,  are  not  digested  without  considerable  labour;  first,  from  their 
evading  the  grappling  powers  of  the  stomach,  and  secondly,  from  their  tena- 
city, opposing  the  absorption  of  their  fluid  parts.  For  these  reasons,  it  is  main- 
tained that  the  addition  of  isinglass,  and  other  glutinous  substances,  to  animal 
broths,  with  a  view  to  render  them  more  nutritive  to  invalids,  is  a  pernicious 
practice. 


64  GENERAL    OBSERVATIONS. 

The  nicety  with  which  these  articles  are  prepared ;  and  the  sa- 
voury nature  of  the  ingredients  which  enter  into  their  composr- 
tions,  are  sure  to  render  them  favourite  articles  with  the  sick ;  on 
whom,  they  are  most  indiscreetly  always,  and  very  often,  most 
injuriously,  urged. 

197.  When  the  composition  of  these  jellies  is  examined,  it 
becomes  a  matter  of  extreme  surprise,  that  they  can  be  present- 
ed to  the  sick,  by  any  rational  or  thinkyig  being,  with  the  most 
remote  prospect  of  their  being  useful.     In  the  first  place,  the 
most  insoluble  portion  of  animal  composition,  forms  the  bases  of 
these  jellies ;  the  smallest  portion  of  which,  in  some  cases  is  suf- 
ficient, as  we  have  before  declared,  (177,)   to  recal  fever  and 
every  other  terrible  consequence  attendant  upon  it — this  it  will 
do  from  its  mere  animal  nature.     But  what  is  superadded  to  this 
glue,  for  such  it  literally  is  ?  wine,  and  highly  stimulating  spices, 
besides,  the  more  innocent  sugar,  and  acid.     Now,  can  any  one 
with  the  slightest  pretension  to  observation,  believe,  that  this 
can  be  a  proper  compound  for  a  patient  labouring  under  fever, 
(be  the  reduction  of  strength  what  it  may,)  or  for  one,  just  reco- 
vering from  it?  we  think  there  is  no  one. 

198.  But  this  is  not  all;  we  have  only  spoken  of  the  highly 
stimulating  qualities  of  the  jellies — another  very  serious  objec- 
tion attaches  to  them  ;  (one  however,  we  shall  not  be  able  to  per- 
suade some,  to  believe  they  deserve,)  namely,  their  great  indi- 
gestibility.     We  are  aware  in  this  assertion,  we  are  running 
counter  to  all  belief  upon  this  point ;  but  it  is  nevertheless,  not 
less  true.     We  say  and  declare  it,  without  the  fear  of  contradic- 
tion from  those,  who  are  qualified  to  investigate  the  point,  that 
the  food  in  question  is  one  of  the  most  insoluble  substances  that 
can  tax  the  powers  of  even  a  hale  stomach;  what  then  must  be 
the  difficulty  to  one,  enfeebled  by  disease,  and  the  operation  of 
medicine  ?  It  were  consummately  to  be  wished,  that  these  baneful 
articles,  could  be  forever  banished  from  the  sick  room. 


CHAPTER  I. 

i  '  •          i 

OF  FEVER  IN  GENERAL. 

199.  HITHERTO   no   definition   of  fever  has  been   given, 
which  is  free  from  all  uncertainty,  or  ambiguity.    It  has  always 
been  so  constructed  as  to  make  its  essence  consist  of  some  one 
circumstance,  or  symptom,  which  rather  betrays  an  hypothesis 
of  the  author,  than  an   essential,  on  which  we  may  implicitly 
rely.  Strictly  speaking,  the  term  fever  implies  heat;  but  a  mere 
increase  of  heat  does  not  constitute  fever,  since,  we  may  have  a 
considerable  augmentation  of  heat  without  the  system  labouring 
under  this  affection ;  and,  on  the  other  hand,  we  may  have  fever 
with  a  cool,  nay,  a  partially  cold  skin,  as  sometimes  happens  in 
yellow  fever. 

200.  Dr.  Cullen  says,  in  fever  there  is  a  sensation  of  chilliness, 
followed  by  an  increase  of  heat;  the  pulse  gives  a  greater  num- 
ber of  strokes  in  a  given  time ;  while  several  functions  of  the 
body  are  more  or  less  impaired,  and  the  strength  of  the  limbs 
particularly,  is  diminished. 

201.  Various  writers  have  raised  objections  to  this  definition 
of  fever;  and  especially  Dr.  Fordyce;  but  his  cavillings  have 
ended  in  a  refinement,  that  rather  perplexes,  than  elucidates. 
We  are,  therefore,  disposed  to  adopt  Dr.  Cullen's  definition, 
though  it  is  confessedly  imperfect.     This  disease  presents  itself 
under  so  varied  a  form,  that  we  are  obliged  in  many  instances 
to  abandon  a  great  part  of  the  best  devised  definition,  and  to  rely 
upon  the  impression  the  bed-side  examination  makes  upon  cer- 
tain of  the  senses,  (as  the  sight  and  touch,)  for  a  knowledge  of 
its  presence. 

202.  We  may,  however,  in  general  remark  in  this  class  of 
diseases,  that  there  are  certain  departures  from  what  is  termed 
the  healthy  standard ;  and  that,  though  in  fever  there  may  not 
be  an  increase  of  heat  over  the  whole  body,  we  can  rarely  find 
a  case  in  which  there  does  not  exist  a  partial  augmentation;  thus, 
we  find  certain  derangements  of  the  system,  (which  we  believe 
the  most  fastidious  stickler  for  definition  would  consent  to  call 
fever,)  attended  with  cold  hands  and  feet,  nay,  perhaps  even 
cold  legs  and  arms,  while  the  head,  the  chest,  and  abdomen, 
may  be  preternaturally  warm;  or  it  may  possibly  happen,  that 
only  one  of  these  parts  shall  have  this  increase  of  heat.     The 
same  uncertainty  may  happen  with  the  pulse ;  its  frequency  by 
no  means  establishes  fever  ;  we  may  have  a  very  frequent  pulse 

9 


66  OP    FEVER   IN    GENERAL. 

without  fever,  or  an  unusually  slow  one  when  it  is  confessedly 
present;  and  this  may,  or  may  not  be,  accompanied  by  an  in- 
crease of  temperature.  The  pulse  may,  therefore,  be  slow  or 
frequent;  strong  or  weak;  hard  or  soft,  with  or  without  fever.* 

"  In  a  very  late,  and  excellent  "Treatise  on  Fever,"  by  Dr.  Southwood 
Smith,  we  find  this  subject  particularly  dwelt  upon.  The  author  has  treated 
the  mooted  point,  in  "  what  fever  essentially  consists,"  with  no  less  candour 
than  ability.  He  has  clearly  shown,  that  no  hitherto  devised  definition,  solves 
this  question.  /He  very  satisfactorily  proves,  that  the  phenomena  of  fever  are 
not  invariable;  and  that  symptoms,  "  are  only  indications  of  events;"  (that  is, 
the  pathological  condition  of  organs;)  and  that  "  symptoms  depend  upon  states 
of  organs;"  and  that  they  are  no  other  than  "the  external  and  visible  signs  of 
internal,  and  for  the  most  part,  as  long  as  life  continues,  invisible  conditions." 
He  therefore  insists,  that  it  is  "  to  the  state  of  the  organs  that  we  must  look  for 
the  events  of  which  we  are  in  search."/He  then  asks,  "are  there  any  states  of 
any  organs  that  always  exist  in  fever?  Are  these  states  constant?  Are  the  or- 
gans affected  constant;  and  can  both  be  ascertained?  If  this  can  be  truly  an- 
swered in  the  affirmative;  if  it  can  be  proved  that  there  are  certain  conditions 
of  certain  organs  which  invariably  exist  in  fever,  in  every  type,  in  every  de- 
gree, in  every  stage  of  it,  we  shall  have  arrived  at  a  satisfactory  conclusion 
relative  to  the  first  part  of  our  inquiry" — namely,  "  What  is  the  series  of  phe- 
nomena which  constitute  fever?"  He  makes  the  "  order  of  events"  to  consist 
of,  "  first,  derangement  in  the  nervous  and  sensorial  functions;"  this  he  declares 
to  be  "the  invariable  antecedent;"  secondly,  "derangement  in  the  circulating 
function;"  this  he  says,  "is  the  invariable  sequent;  and  thirdly,  derangement 
in  the  secreting  and  excreting  functions,"  which  he  considers  as,  "  the  last 
result  in  the  succession  of  morbid  changes."  From  this  view  of  the  subject, 
he  infers,  that  in  every  instance  of  fever,  that  there  constantly  and  invariably 
exists,  derangement  in  these  three  grand  divisions  of  organs,  and  functions; 
and  consequently,  that  "  we  are  in  possession  of  the  true  characters  of  fever." 
And  also,  that  "  we  know  the  events,-  we  know  the  order  in  which  they  occur; 
we  know  therefore  what  it  is  that  constitutes  the  disease,  and  consequently, 
we  know  what  it  is  by  which  it  is  distinguished  from  every  other  malady.  No 
other  disease  exhibits  the  same  train  of  phenomena  in  the  same  order  of  suc- 
cession." Agreeably  therefore  to  this  view  of  fever,  the  symptoms  which  at- 
tend it,  are  but  signs  of  the  anormal  condition  of  the  three  great  divisions  of 
the  system,  and  which  may  vary  almost  infinitely,  but  that  it  is  essential  to 
fever,  that  the  events  just  named  should  all  exist,  and  follow,  in  the  order  just 
noted.  For  Dr.  S.  insists  that  "no  other  disease  exhibits  the  same  train  of 
phenomena  in  the  same  order." — pp.  47,  48,  50.  It  may  also  be  useful  in  a 
pathological  sense,  if  not  immediately  in  a  practical,  to  put  those,  who  may  not 
be  able  to  command  the  work,  in  possession  of  Dr.  Smith's  distinction  be- 
tween "  fever  and  inflammation,"  as  their  identity  is  insisted  upon  by  some 
practical  and  pathological  writers. 

"  Supposing  the  matter  of  fact  be  as  here  stated,"  (as  regards  the  events  and 
their  invariable  succession,)  "it  is  clear  that  we  are  in  possession  of  the  true 
characters  of  fever."  "  In  inflammation  some  of  the  phenomena  are  the  same; 
but  the  order  in  which  they  occur  is  not  the  same;  and  this  affords  a  clear  and 
universally  applicable  mark  of  distinction  between  fever  and  inflammation.  In 
inflammation  there  is  similar  derangement  in  the  secreting  and  excreting  func- 
tions; there  is  also  sometimes  similar  derangement  in  the  circulating  function; 
but  the  derangement  in  the  nervous  and  sensorial  functions  is  seldom  if  ever 
similar;  the  derangement  that  does  take  place  in  these  latter  functions,  while 
it  is  apparently  different  in  kind,  is  certainly  and  invariably  different  in  the 
order  of  their  occurrence.  In  pneumonia,  in  enteritis,  in  hepatitis,  the  spinal 
cord  and  the  brain  are  never  the  organs  in  which  the  first  indications  of  disease 


OP    FEVER    IN    GENERAL.  67 

203.  Lassitude,  with  more  or  less  disturbance  of  the  mind, 
almost  invariably  attend  fever — and  some  evidences  of  debility 
almost  always  manifest  themselves  a  short  time  before  its  regular 
formation  ;  the  last  never  fails  to  accompany  fever ;  but  its  degree 
seems  rather  to  depend  upon  the  nature  of  the  agent  giving  rise 
to  fever,  than  upon  the  violence  of  the  symptoms  which  may  at- 
tend it.     This  can  easily  be  illustrated,  by  comparing  pleurisy 
with  the  typhus  of  Cullen,  and  other  writers. 

204.  The  order  of  the  symptoms  which  attend  fever,  has  given 
rise  to  the  division  of  them  into  several  kinds ;  and  it  is  by  ob- 
serving the  succession  and  continuance  of  their  phenomena,  that 
we  are  enabled  to  declare  to  which  particular  variety  the  fever 
in  question  may  belong.     Each  of  these  varieties  may  require 
some  difference  of  treatment,  as  shall  be  observed  when  treating 
of  fevers  individually. 

205.  But,  notwithstanding  the  many  kinds,  or  varieties  of 
fever*  made  by  some,  they  all  have  a  general,  as  well  as  a  par- 
ticular plan  of  treatment ;  we  shall,  therefore,  point  out  several 
important  directions  which  will  apply  to,  every  species,  or  va- 
riety. 

appear.  The  earliest  indications  of  disease  that  can  be  discovered  have  their 
seat  in  the  affected  organ  itself;  it  is  only  after  the  disease  has  made  some  pro- 
gress that  other  organs  and  functions  are  involved;  and  apparently,  the  last  to 
be  involved,  and  certainly  the  last  to  suffer,  is  the  nervous  system." 

"  We  can  now  then  answer  the  questions  so  often  asked — are  fever  and  in- 
flammation  the  same?  and  if  not  the  same,  in  what  do  they  differ?  Fever  and 
inflammation  are  not  the  same;  because  the  term  fever  is  appropriated  to  de- 
signation of  a  certain  number  of  events  which  occur  in  a  certain  series;  the  term 
inflammation,  on  the  other  hand,  expresses  another  series  of  events,  each  event 
comprising  this  train,  succeeding  each  other  in  a  different  order;  and  the  dif- 
ference between  the  two  series  of  events  is  precisely  this  difference  in  their 
individual  phenomena  and  in  their  order  of  succession.  What  the  physical  and 
physiological  condition  of  the  organs  is,  as  contrasted  with  their  condition  in 
the  state  of  health,  Has  not  yet  been  made  out  with  regard  either  to  fever  or  to 
inflammation — therefore  in  the  present  state  of  our  knowledge,  we  can  neither 
affirm  or  deny  any  thing  respecting  either  the  identity  or  the  difference  of  that 
physical  and  physiological  condition  of  the  organs  in  these  two  classes  of  dis- 
ease. What  inflammation  is  beyond  the  series  of  events  we  are  able  to  observe, 
we  do  not  know;  what  fever  is  beyond  the  series  of  events  we  are  able  to  ob- 
serve, we  do  not  know;  we  compare  the  events  and  we  see  they  differ;  and 
since  the  use  of  names  is  to  mark  and  express  differences,  it  is  right  to  distin- 
guish these  different  events  by  different  terms.  But  though  in  our  present 
state  of  knowledge  we  are  not  justified  in  considering  fever  and  inflammation 
to  be  the  same,  yet  the  close,  perhaps  constant  connexion  between  them,  is  a 
fact  of  the  utmost  consequence  to  be  known,  and  requires  to  be  incessantly  be- 
fore the  view  of  the  practitioner." 

*  We  have  already  remarked  upon  the  absurdity  of  multiplying  the  varie- 
ties of  fever  to  the  extent  which  some  have  done;  especially,  as  practical 
utility  is  not  advanced  by  it;  for  in  the  cure  of  fevers,  all  have  to  be  treated 
more  or  less  upon  the  same  general  principles;  though  certain  of  them,  may 
exact  a  specific  management. 


68  OF    FEVER    IN    GENERAL. 

206.  As  there  is  for  the  most  part  an  augmentation  of  heat,  it 
becomes  highly  useful  to  preserve  a  proper  temperature  in  the 
sick  chamber.    (See  p.  37.)    Artificial  heat  should  not  be  added 
to  the  patient  through  the  medium  of  the  air;  therefore  the  fire, 
if  in  winter,  or  cool  weather,  should  be  so  regulated,  as  not  to 
raise  the  temperature  of  the  chamber  equal  to  that  of  the  pa- 
tient's body;  by  this  means  there  will  be  a  gradual  subtraction  of 
caloric;  which  will  not  only  be  very  comforting  to  the  sick,  but 
very  useful  as  a  remedy.  Artificial  heat  may  frequently  be  very 
advantageously  employed  in  such  fevers,  or  periods  of  fevers,  as 
are  accompanied  with  a  partial  diminution  of  it — as  in  the  feet, 
legs,  hands,  arms,  &c.   For,  though  we  should  deprecate  its  em- 
ployment when  a  generally  diffused  increase  of  temperature  ex- 
isted, yet  we  shall  find  it  very  beneficial  where  the  contrary  ob- 
tains.    For  this  purpose,  warmed  flannels,  jugs  or  bottles  filled 
with  warm  water,  heated  bricks,  &c.  may  be  used  to  the  parts 
that  are  preternaturally  cold,  with  decided  advantage. 

207.  It  is  not  only  important  to  attend  to  the  temperature  of 
the  room,  that  the  air  be  not  over-heated,  but  also,  that  this  air 
is  frequently  renewed.   (See  p.  36.)     In  many  situations  it  will 
require  considerable  caution,  that  the  patient  may  not  be  exposed 
to  a  direct  current — this  of  course  must  be  guarded  against  in 
the  best  manner  circumstances  will  permit — a  door,  or  a  win- 
dow, or  both,  may  be  advantageously  left  open  with  a  view  to 
refresh  the  room  ;  and  this  may  be  done  even  in  cold  weather, 
provided  the  patient  be  protected  from  its  direct  influence.  This 
ventilation  is  especially  necessary  in  small  and  confined  rooms; 
and  in  warm  weather. 

208.  The  air  of  the  room  should  be  so  regulated  as  not  to  have 
its  temperature  too  much  increased;  nor  to  become  stagnant,  and 
loaded  with  the  emanations  from  the  patient's  body;  to  guard 
more  effectually  against  the  latter,  there  should  be  no  curtains  to 
the  sick  bed.      Should  the  situation  of  the  patient's  bed  be  such, 
as  unavoidably  to  be  exposed  to  a  current  of  air,  when  about  to 
ventilate  the  chamber,  a  partial  drapery  may  be  given  to  the 
bedstead,  by  hanging  up  a  sheet,  so  as  to  intercept  the  draught — 
and  this  will  always  be  sufficient*     And  to  preserve  the  air  as 

*  Great  care  should  be  taken,  that  the  patient  be  not  exposed  to  a  draught 
of  air,  while  he  is  sweating,  or  even  when  his  skin  is  moist,  or  when  the  tem- 
perature of  his  body  is  below  the  natural  standard,  and  these  perhaps  are  the 
only  reasons  for  being  particular  upon  this  point.  For  when  the  temperature 
of  the  patient's  skin  is  very  much  exalted,  we  do  not  see  that  injury  can  arise 
from  cool  air  passing  over  the  body,  more  than  shall  follow  the  sponging  of  it 
with  cold  fluids.  Yet  it  is  well  to  suggest  the  caution;  as  it  will  perhaps  pre- 
vent the  application  of  cold  air,  when  it  might  be  injurious,  from  the  moist 
condition  of  the  skin;  or  when  the  surface  of  the  skin  is  too  low  in  tempera- 
ture. 


OF   FEVER   IN    GENERAL.  69 

much  as  possible  from  contamination,  nothing  that  could  do  mis- 
chief to  it,  should  be  suffered  to  remain — therefore  the  evacua- 
tions of  every  kind  must  be  removed  as  speedily  as  possible. 
No  culinary  operations  should  be  performed  in  the  room  when 
it  can  be  ordered  otherwise — as  all  strong  smells,  especially 
those  arising  from  cooking,  are  extremely  offensive,  as  well  as 
injurious,  to  the  sick. 

209.  The  floor  of  the  room  in  warm  weather  should  be  kept 
clean  and  sweet,  by  passing  a  wet  cloth  over  it  once  or  twice  a 
day — but  the  room  is  not  to  be  flooded  with  water,  for  the  pur- 
pose of  scrubbing — the  room  may  be  much  refreshed  by  having 
the  floor  frequently  sprinkled  with  pure  vinegar.     Carpets,*  es- 
pecially in  hot  weather,  should  be  removed  from  the  floor;  and 
when  practicable,  may  be  replaced  by  mats — even  in  winter,  the 
carpet  should  be  removed  occasionally,  and  exposed  to  the  fresh 
air — this  in  certain  fevers  becomes  highly  important,  nay  indis- 
pensable.    This  is  particularly  important  in  dysentery,  or  other 
affections  of  the  bowels,  as  these  articles  retain  the  smell  from 
the  evacuations  for  a  long  time. 

210.  As  there  is  in  almost  all  cases  of  fever,  a  strong  determi- 
nation to  the  head,  or  head-ache,  we  should  be  careful  to  keep 
the  patient  as  quiet  as  possible;  and  should  delirium  attend,  we 
should  guard  with  all  possible  care,  against  company,  or  any 
other  circumstance,  that  might  tend  to  augment  it.     To  aid  in 
this  intention,  the  room  should  be  kept  as  dark  as  proper  venti- 
lation will  permit,  and  all  objects  should  be  removed,  that  par- 
ticularly challenge  the  patient's  attention.   He  must  not  see  com- 
pany; and  as  few  faces  should  present  themselves,  as  is  compa- 
tible with  proper  and  careful  nursing.     No  unnecessary  conver- 
sation should  be  indulged  in;  and  above  all,  low  whisperings 
must  be  strictly  forbidden.     When  conversation  is  necessary, 
it  should  be  carried  on  in  a  tone  of  voice,  that  will  enable  the  pa- 
tient, if  he  chose  to  listen,  to  comprehend  it  easily — this  will  save 
him  much  exertion,  and  will  prevent  much  solicitude.     As  the 
patient  always  imagines  himself  to  be  the  subject  of  the  confer- 
ences, that  take  place  in  the  sick  room,  it  will  readily  suggest 
itself  that,  all  unpleasant  anticipations  of  the  event  of  the  patient's 
disease,  must  be  avoided  in  his  presence.     (See  p.  34,  par.  65.) 

211.  It  is  erroneously  imagined,  that  people  labouring  under 
fever,  are  extremely  liable  to  "  catch  cold,"  as  it  is  termed;  to 
prevent  this,  bed-clothes  are  heaped  upon  him  almost  to  suffo- 

*  In  cases,  attended  by  delirium,  or  extreme  head-aches,  it  may  be  useful 
to  have  the  floor  carpetted,  as  it  diminishes  the  noise  from  walking.  Indeed  it 
is  desirable,  in  all  cases  of  fever,  that  the  patient  should  be  disturbed  as  little 
as  possible  by  noise;  that  which  might  arise  from  walking,  can  always  be  ob- 
viated, by  the  attendants  wearing  socks3  or  very  soft  slippers. 


70  OP    FEVER   IN    GENERAL. 

cation — this  is  a  mistake,  and  should  be  guarded  against;  for 
the  patient  should  have  no  more  clothing  than  is  absolutely  ne- 
cessary to  prevent  his  feeling  chilly — all  covering  beyond  this 
is  both  useless  and  injurious.  The  bed-clothing  therefore  should 
be  constantly  regulated  by  the  feelings  of  the  patient.  (See  p. 
38,  par.  89.) 

212.  To  patients,  labouring  under  fever,  nothing  is  more  ac- 
ceptable than  cool  drinks,  nor  is  there  any  thing  more  proper. 
An  unfortunate  and  vulgar  error  prevails  on  this  head.     It  is  im- 
agined that  all  the  drinks  for  such  patients  should  be  warm,  with 
a  view,  they  say,  of  disposing  to,  or  provoking  perspiration ;  by 
this  reasoning,  the  patient  is  deprived  of  almost  the  only  luxury 
he  dare  indulge  in,  as  well  as  debarred  sometimes  from  an  im- 
portant remedy.     We  would  therefore  recommend  that  all  the 
drinks  of  the  patient  should  be  cool;  nay,  sometimes  cold — and 
this  is  easily  regulated;  as  the  degree  of  external  heat  of  the  pa- 
tient should  be  the  uniform  guide.  Nor  are  we  aware,  that  there 
is  an  exception  to  this,  but  where  the  skin  is  moist,  or  disposed 
to  be  so.     Where  perspiration  has  taken  place,  or  is  just  about 
to  take  place,  the  liquids  should  not  be  cold,  although  they  may 
be  cool. 

213.  For  we  have  very  often  seen  a  profuse  perspiration  im- 
mediately follow  a  drink  of  cold  water;  and  we  never  hesitate 
to  administer  it,  when  the  skin  is  hot  and  dry,  and  the  thirst 
great ;  nor  even  to  repeat  it  from  time  to  time  under  like  cir- 
cumstances. It  however  very  often  happens  in  the  higher  grades 
of  fever,  that  the  thirst  demands  more  drink  than  the  stomach 
can  well  support — for  if  cold  drinks  be  too  much  indulged  in, 
the  stomach  revolts,  and  a  vomiting  ensues.     To  prevent  this, 
we  are  in  the  habit  of  giving  small  portions  of  ice*  from  time  to 
time.  By  this  plan  we  secure  to  the  patient,  a  more  permanently 
cold  application  to  the  mouth;  while  the  stomach  enjoys  all  the 
advantages  of  cold  water,  without  its  oppressive   weight  and 
bulk.     Or  if  ice  cannot  be  commanded,  cold  water  may  be  given 
by  the  spoonful,  and  repeated  more  frequently. 

214.  The  drinks  of  fever  patients  should  consist  of  such  arti- 
cles as  are  most  palatable;  but,  at  the  same  time  they  should  be 
such,  as  are  free  from  all  stimulus,  unless  the  latter  comports 
with  the  particular  situation  of  the  patient;  in  this  case  it  forms 
rather  an  exception,  than  a  rule.t     We  should  therefore  say, 
that  in  all  cases  which  do  not  require  such  stimulating  articles, 
as  wine,  brandy,  &c.  to  be  added,  (and  these  are  almost  all  cases 

*  The  ice  should  be  broken  into  pieces  of  the  size  of  a  filbert,  and  placed 
at  the  command  of  the  patient;  and  of  which  he  may  swallow  freely. 

f  It  will  be  seen,  by  the  sequel,  how  very  few  the  exceptions  are  to  this 
rule. 


OF   FEVER   IN   GENERAL.  71 

of  fever,)  the  drink  should  consist  of  toast  water,  baum  tea,  le- 
monade, current  jelly  and  water,  molasses  and  water  with  a  lit- 
tle vinegar,  the  water  off  of  dried  cherries,  very  weak  milk  and 
water,  barley  water,  flaxseed  tea,  either  with  or  without  lemon 
juice,  sorrel  water,  &c.  &c.  We  have  purposely  enumerated  a 
variety  of  drinks,  that  the  invalid  may  have  a  choice.  But  sim- 
ple cold  water,  as  just  noticed,  is  almost  always  admissible,  as 
well  as  grateful,  especially  when  there  is  great  heat. 

215.  Food  should  be  administered  with  the  greatest  caution; 
and  this  refers  not  only  to  the  quantity,  but  also  to  the  quality — 
it  should  be  of  the  lightest  kind,  especially  in  the  inflamma- 
tory stages  of  the  disease.     Indeed,  the  patient  frequently  pro- 
fits by  the  kind  interference  of  nature,  when  she  deprives  him 
of  all  inclination  to  receive  it.     In  this  country,  we  are  subject 
to  many  highly  inflammatory  diseases,  in  which,  the  more  com- 
plete the  abstinence,  the  more  the  patient  profits.    There  can  be 
no  error  more  injurious,  than  the  belief,  that  the  sick  are  in  con- 
stant need  of  nourishment.     This  prejudice  has  destroyed  its 
thousands — and  it  is  one  of  the  first  and  most  important  rules  to 
be  learnt  by  those  who  have  charge  of  the  sick,  that  in  the  com- 
mencement of  any  acute  disease,  little  or  no  food  is  required. 

216.  In  no  instance  of  fever,  or  any  other  disease  of  high 
action,  is  animal  food,  in   any  possible  shape   or  disguise,  as 
broths,  &c.  admissible — during  convalescence,  it  may  be  useful. 

217.  When  it  is  proper  to  administer  nourishment  in  fever, 
it  should  always  be  given  in  small  quantities  at  a  time — say 
three  or  four  spoonfuls  either  large  or  small,  as  the  patient  may 
be  either  large  or  small.     It  should  consist  of  weak  milk  and 
water;  thin  tapioca;  sago  or  arrow  root;  gruel,  either  of  Indian 
meal  or  oat  meal;  ripe  fruits  in  moderate  quantities,  when  in 
season,  such  as  oranges,  grapes,  or  roasted  apple,  may  also  be 
given.      Gum  Arabic  water,  is  perhaps  one  of  the  least  excep- 
tionable articles  of  diet  we  can  recommend.     A  cup  of  weak  tea 
or  coffee  is  frequently  extremely  grateful  to  the  sick;  and  may 
almost  always  be  permitted. 

218.  We  can  scarcely  be  too  particular  in  the  body-clothes  of 
the  patient;  they  should  be  daily  changed  when  the  patient  is 
not  too  much  exhausted  to  permit  this — the  bed-linen  should 
also  undergo  a  daily  removal  when  it  is  practicable;  and  espe- 
cially in  those  fevers  that  end  their  paroxysms  by  sweat. 

219.  We  have  already  intimated  that  much  of  the  success  in 
the  cure  of  fevers  will  depend  upon  the  promptitude  with  which 
remedies  may  be  had  recourse  to;  and  upon  the  fidelity  with 
which  they  may  be  administered ;  and  these  must  be  aided  by 
the  strictest  attention  to  the  proper  regimen.     Indeed,  without 
the  latter,  the  former  would  for  the  most  part  be  entirely  un- 
availing— much  then  depends  upon  the  nursing  as  it  is  termed. 


72  OF    FEVER    IN    GENERAL. 

(See  p.  31,  par.  56,  &c.)  The  intervals  at  which  medicine  is  di- 
rected to  be  exhibited  should  be  carefully  attended  to;  as,  a  fail- 
ure in  this,  has  frequently  defeated  a  well-devised  plan  of  cure.  A 
mistaken  tenderness  should  not  interfere  with  a  prescribed  or  an 
imperious  duty;  nor  should  it  interrupt  the  application  of  an  im- 
portant, though  perhaps  a  painful  remedy.  There  is  a  time  or 
period  in  almost  every  disease,  at  which  a  remedy  is  the  most 
important;  but  if  this  time  be  allowed  to  pass,  from  mistaken 
kindness,  indecision,  or  neglect,  it  may  perhaps  never  return. 
Therefore  remedies,  to  be  efficacious,  must  be  promptly  applied, 
and  rigorously  persevered  in. 

General  Plan  of  Cure. 

220.  In  fevers  of  almost  every  description,  (as  we  have  before 
declared,)  that  state  of  the  system  called  inflammatory,  prevails; 
and  in  the  commencement  of  all,  it  would  scarcely  be  too  much 
to  say  that,  a  preternatural  fulness  exists;  so  that  we  rarely  meet 
with  a  fever,  on  the  onset  of  which,  we  do  not  find  the  blood- 
vessels more  than  naturally  active.     When  the  contrary  obtains, 
it  is  almost  always  in  some  uncommon  epidemic  or  southern 
endemic;  and  these  only  form  exception  to  the  rule.     We  have 
therefore  almost  always  to  contend  in  the  early  stage  of  fever 
.with  an  augmented  heat;  increased  pulse;  perhaps  with  loaded 
stomach  and  bowels;  our  remedies  must  therefore  be  calculated 
to  diminish  the  two  first,  and  remove  the  latter. 

221.  These  intentions  are  to  be  fulfilled  by,  1st,  cool  or  cold 
air;  cool  or  cold  drinks;  and  by  such  remedies, as  are  indirectly 
calculated  to  produce  this  end;  2d,  bleeding;  3d,  sweating;  4th, 
purging;  5th,  blistering;  6th,  tonics,  &c. 

A.    Of  Cool  Jiir  and  Drinks.  * 

222.  We  have  already  noticed  the  importance  of  fresh  and 
cool  air  to  the  body  of  a  patient  labouring  under  fever,  and  we 

*  As  the  terms  hot  and  cold?  warm  and  cool,  are  relative,  it  may  be  well  to 
offer  a  more  precise  meaning"  to  them  in  this  place.  When  speaking1  of  cold 
or  cool  air,  we  should  wish  to  be  understood  that  degree  of  it,  which  would 
excite  these  sensations  in  the  patient;  thus  when  the  body  is  heated  to  108° 
or  110°,  diminution  of  15°  would  appear  cold — should  it  be  at  100°  it  will  bear 
a  greater  reduction,  before  the  sensation  would  be  called  cold;  it  would  follow 
then  of  course  that,  the  intermediate  degrees  would  be  called  cool — when 
speaking1  of  cold  or  cool  drinks,  we  must  be  understood  to  mean  in  general 
from  40°  to  57£°  for  the  first;  and  for  the  second  from  57°  to  60°. 

And  further  we  would  wish  it  to  be  understood,  when  we  speak  of  the  tem- 
perature of  the  air  of  a  sick  chamber,  to  mean  that  it  should  never  exceed  62°, 
where  practicable  to  keep  it  in  this  condition,  during  the  hot  stage  of  fever. 
If  chill  exist,  there  is  no  objection  to  a  more  exalted  temperature  for  the  time 
being. 


OP    FEVER    IN    GENERAL.  73 

now  wish  to  be  understood  to  consider  this  as  not  only  highly 
refreshing  to  the  patient,  but  as  a  valuable  and  active  remedy. 
Whenever  therefore  the  surface  of  the  body  is  above  the  natural 
temperature,  we  should  so  employ  this  remedy  as  to  remove 
this  superfluous  heat.  To  do  this  in  the  safest  and  most  effica- 
cious manner,  we  should  permit  the  constant  introduction  of 
fresh  air  into  the  chamber;  and  the  patient  should  be  so  situated 
as  to  derive  full  advantage  from  it,  but  without  incurring  the 
risk  of  a  full  stream  directed  immediately  upon  him,  if  his  skin 
be  moist.  In  hot  weather  however,  this  will  require  but  few 
precautions;  as  the  external  air  in  some  of  our  hottest  days,  is 
perhaps  but  little  below  the  heat  of  the  patient;  in  this  case,  no 
risk  is  run,  in  having  a  current  directed  immediately  over  him. 
To  obtain  this  advantage,  his  bed  should  be  removed  to  the 
most  open  part  of  the  room,  and  his  covering  be  as  thin  as  pos- 
sible. Where  the  temperature  of  the  external  air  is  considerably 
lower  than  the  heat  of  the  patient,  it  must  be  applied  in  such  a 
manner  as  not  to  induce  a  sudden  chilliness — and  this  can  al- 
ways be  effected  by  giving  a  proper  direction  to  the  air,  and  ac- 
commodating the  bed-cloathing  to  the  state  of  the  atmosphere. 
The  sensation  this  regulation  produces  in  the  patient  when  pro- 
perly managed,  is  that  of  the  most  delightful  cordial.  The  de- 
gree of  cold  therefore,  must  be  commensurate  with  the  degree 
of  heat,  the  patient  has  to  spare. 

223.  In  situations  where  cold  air  cannot  be  commanded,  the 
application  of  cool  or  cold  water  to  the  arms,  head,  and  body  of 
the  patient,  by  means  of  a  sponge  passed  over  them,  will  be 
found  highly  refreshing,  as  well  as  useful.     But  in  the  employ- 
ment of  these  remedies,  it  must  be  recollected,  it  is  never  to  be 
had  recourse  to  while  the  body  is  sweating,  or  when  the  tem- 
perature of  the  body  has  been  reduced  by  cool  applications,  (as 
sometimes  happens,)  so  as  to  induce  perspiration.    The  sponging 
must  be  now  desisted  from,  until  the  perspiration  disappear,  and 
until  a  re-accumulation  of  heat  make  it  again  necessary.    Should 
cough,  or  other  affections  of  the  chest  attend,  the  sponging  must 
not  be  thought  of. 

224.  Cool,  or  even  cold  drinks,  we  have  said,  are  most  grate- 
ful and  most  useful  in  fever.     In  very  hot  weather,  their  tempo* 
rature  can  be  speedily  and  advantageously  reduced  by  ice.     In 
this  state,  they  may  with  great  propriety  be  employed,  if  they 
be  exhibited  in  small  quantities  at  a  time,  as  has  already  been 
observed;  the  quantity,  however,  may  be  frequently  repeated. 
The  kind  of  drink  has  already  been  pointed  out.    The  same  pre- 
cautions should  be  observed  with  cold  drinks  as  with  cold  air, 
when  the  body  is  in  a  state  of  moisture  from  perspiration;  but 
we  need  not  withhold  cold  drinks  if  cough  alone  be  present. 

10 


74 


OF    FEVER    IN    GENERAL. 


225.  Fevers  of  every  denomination,  be  their  types  what  they 
may,  frequently  have  sickness  of  stomach  as  an  attendant.    This 
nausea,  or  it  may  amount  occasionally  to  vomiting,  is  always 
attributed  by  the  attendants  upon  the  sick,  to  "afoul  stomach" 
and  in  their  opinions,  decidedly  calls  for  an  emetic.     This,  nine 
times  out  of  ten,  is  an  error;  for  this  sickness,  &c.  only  points 
out  a  state  of  irritation  of  this  organ;  and  so  far  from  its  being 
relieved  by  an  emetic,  is  almost  certainly  aggravated  by  it.     In 
such  cases,  cathartic  medicines  of  a  moderately  active  kind 
should  first  be  given,  and  if  these  do  not  afford  relief,  try,  2d, 
the  direct  application  of  such  remedies  as  are  known  for  their 
efficacy  in  such  cases;  and  3d,  if  these  fail,  counter-irritants  must 
be  used. 

226.  The  first  will  consist  of  small  quantities  of  calomel,  fol- 
lowed if  necessary  by  magnesia.   For  much  advantage  is  derived 
in  this  condition  of  the  stomach  from  small  portions  of  calomel, 
repeated  at  short  intervals,  viz. 

R.     Calom.  ppt.  -        gr.  viij.    Take  Calomel  8  grains. 

Sacch.  alb.  -        gr.  viij.  White  sugar          -        8  grains. 

M.  div.  in  viij.  Mix,  divide  in  8  parts. 

One  of  these  should  be  given  every  hour  in  a  drop  of  syrup  of 
any  kind,  or  a  little  scraped  apple,  until  they  move  the  bowels. 

227.  But  should  this  quantity  not  stir  the  bowels,  and  relieve 
the  sickness,  let  two  or  three  tea-spoonfuls  of  calcined  magnesia 
in  a  little  sweetened  milk  be  given;  or  else,  give  an  enema;  in- 
deed this  may  be  profitably  employed  whenever  the  stomach  is 
thus  irritable,  and  the  bowels  tardy.     It  may  consist  simply  of 
hot  water  and  common  salt,  in  the  proportion  of  a  pint  of  the 
former  to  a  large  table-spoonful  of  the  latter.     This  may  be  re- 
peated as  necessity  may  require.     Should  this  fail,  it  will  be  pro- 
per to  employ  the  second  set  of  remedies,  and  the  milder  of 
these  should  be  tried  first;  these  will  consist,  of  small  quantities 
at  a  time,  of  pretty  rich   gum  Arabic  water,  (cold,)  milk  and 
water,  in  small  quantities — that  is,  a  table-spoonful  every  fifteen 
or  twenty  minutes;  or  we  may  use  with  almost  a  certainty  of 
success,  the  following  more  complicated,  but  very  successful 
julep. 


R. 


Bis-carbon,  sodz 
Pulv.  gum  arab. 
Ol.  minthz 
Sacch.  alb. 
Aq.  Seltzer 


-       3U- 
gut.  iv. 


Take  super-saturated  soda  1^  drachm. 
Powdered  gum  arabic  2    do. 
Oil  of  mint          -        4  drops. 
White  sugar        -        2  drachms. 
Seltzer  water      -        4  ounces. 


Of  this,  a  table-spoonful  may  be  taken  every  half  hour  or  hour, 
as  the  necessity  may  be  more  or  less  urgent.  If  the  Seltzer 
water  cannot  be  commanded,  simple  water  will  answer. 

228.   Should  neither  of  these  answer,  we  must  have  recourse 


OF    FEVER    IN    GENERAL.  75 

to  the  third  set  of  remedies;  a  few  ounces  of  blood  drawn 
from  the  region  of  the  stomach,  by  leeches,  will  be  found  to  be 
of  decided  use.  This  operation  may,  if  necessary,  be  followed 
or  preceded  by  a  plaster  of  the  flower  of  mustard  and  vinegar  to 
the  stomach  until  it  tingles  the  skin  smartly;  or  it  may  be  useful 
to  apply  a  blister,  if  the  vomiting  be  obstinate. 

B.  Of  Bleeding. 

229.  The  employment  of  this  valuable  remedy  in  the  com- 
mencement of  fevers,  is  now  so  universal,  that  it  has  almost  be- 
come a  domestic  remedy;  and  the  number  of  cases  in  which  it 
is  useful,  nay,  essential,  is  so  great  that  we  may  look  upon  it  as 
almost  indispensable.     The  prejudices  which  were  so  long  en- 
tertained against  it,  have  given  place  to  the  confidence,  which 
experience  has  shown,  it  merited;  and  it  is  now  in  such  general 
acceptance,  that  it  is  very  frequently   the  initiatory  remedy. 
The  cases  of  fever  in  which  this  mode  of  depletion  is  inadmissi- 
ble are  so  few,  that  we  find  almost  a  difficulty  in  pointing  them 
out — at  least  in  the  commencement;  and  it  is  at  this  period,  we 
are  always  presumed  to  refer,  whenever  we  speak  of  remedies 
in  general,  unless  the  contrary  is  expressly  declared. 

230.  Although  blood-letting  is  almost  universally  prescribed 
for  fevers  in  this  country,  it  must  nevertheless,  be  looked  upon 
as  a  remedy  of  great  power,  and  of  course  must  be  judiciously 
directed.    For,  that  it  may  be  employed  advantageously,  it  must 
be  used  at  proper  times,  in  proper  quantity,  and  under  proper 
circumstances. 

231.  The  proper  time  for  bleeding,  is  for  the  most  part  at  the 
period  at  which  the  hot  stage  of  fever  is  completely  formed — it 
should,  therefore,  never  be  used  in  the  cold  stage  of  fever;*  nor 
when  the  paroxysm  has  subdued,  or  is  about  to  subside.     As  a 
general  rule,  it  should  not  be  used  during  the  sweating  stage ; 
there  are,  however,  exceptions  to  this — as  in  certain  cases  of 
yellow  fever;  and  also  in  some  instances  of  common  remittents, 
where  the  sweating  does  not  mitigate  the  symptoms,  or  lower 
the  pulse. 

232.  The  quantity  to  be  drawn  is  of  much  importance — on 
this,  almost  every  thing  depends;  for  if  too  little  be  drawn, 
which  is  by  far  the  more  common  error,  very  little  advantage  is 
derived;  and  if  too  much  be  taken,  mischief  must  necessarily 

*  The  contrary  of  this  has  lately  been  recommended  in  such  strong  terms, 
by  a  physician  in  Great  Britain  that  our  opposition  is  something'  diminished, 
but  not  so  much  so,  as  to  induce  us  to  give  it  our  concurrence.  We  are  willing 
to  acknowledge,  that  this  may  be  prejudice;  but  until  more  experience  shall 
establish  its  utility,  we  must  abide  by  our  present  prepossessions. 


76  OF    FEVER    IN    GENERAL.' 

follow.  The  latter,  however,  as  far  as  our  experience  goes,  is 
an  accident  of  rare  occurrence;  and  when  it  does  happen,  is  much 
more  easily  remedied,  in  very  severe  diseases,  than  where  too 
little  has  been  taken  at  an  important  period  of  the  complaint. 
As  a  common  practice,  where  this  remedy  is  necessary,  we 
should  permit  the  blood  to  flow,  until  it  produces  a  manifest 
change  in  the  feel  of  the  pulse — the  pulse  should  become  quicker, 
smaller,  softer,  and  fluttering,  as  it  were,  under  the  finger.  It 
is  to  be  remarked  here,  however,  that,  in  this  direction,  we  have 
reference  to  the  intense  forms  of  disease. 

233.  In  the  milder  forms  of  fever,  where  the  pulse  is  not  much 
excited,  but  yet  requiring  the  loss  of  blood  from  local  determi- 
nation, and  especially,  when  this  is  to  the  head,  we  may  content 
ourselves  with   a  quantity,   which  shall   merely  diminish    the 
strength  and  fulness  of  the  pulse.     But  in  cases  in  which  the 
head  is  very  much  affected,  it  is  for  the  most  part  a  good  rule, 
to  allow  the  blood  to  flow,  until   relief  is  experienced.     From 
this  it  will  be  perceived,  that  it  is  very  difficult  to   direct  the 
precise  quantity  of  blood  to  be  subtracted  by  any  fixed  number 
of  ounces. 

234.  As  a  general  rule,  the  blood  should  be  drawn  from  a 
large  orifice;  in  many  instances,  by  an  observance  of  this,  the 
loss  of  less  blood  is  found  to  answer,  as  the  effects  upon  the  sys- 
tem are  much  more  decided ;  this  is  especially  important  in  the 
commencement  of  the  disease;  and  where  it  is  presumable  from 
its  force,  that  much  blood  will  be  required.     With  such  as  may 
be  disposed  to  faint,  from  the  mere  operation  of  bleeding,  the 
precaution  should  be  taken  to  bleed  in  a  recumbent  posture.   But 
when  this  is  not  the  case,  and  it  is  desirable  to  make  a  consider- 
able impression  on  the  sanguiferous  system,  the  contrary  should 
be  observed,  as  the  tendency  to  faint,  is  at  times  highly  useful ; 
especially,  in  those  fevers  in  which  there  is  very  strong  arte- 
rial action,  with  great  determination  to  the  head.* 

235.  The  number  of  times  a  patient  may  be  bled  for  the  cure 
of  fever,  can  never  be  pointed  out  in  round  numbers — the  repe- 
tition must  depend  upon  the  force  with  which  the  disease  mani- 
fests itself  in  the  sanguiferous  system — and  this  for  the  most  part 
the  pulse  will  indicate. 

236.  But  the  pulse  is  not  always  to  be  the  guide,  especially 

*  In  general,  in  fevers,  when  either,  from  the  peculiar  nature  of  the  disease, 
as  an  epidemic;  or  from  the  particular  constitution  of  the  patient,  the  determi- 
nation of  blood  to  the  head  is  strongly  marked  by  head-ache,  or  delirium,  the 
position  of  the  patient  is  no  mean  point  to  be  observed.  He  should  always 
have  his  head  and  shoulders  so  much  elevated,  as  will  bring  the  blood  within 
the  certain  influence  of  gravitation.  Indeed,  this  rule  should  always  be  ob- 
served in  such  affections  of  the  brain  or  its  appendages,  as  betray  an  excess  of 
blood  in  them. 


OF    FEVER    IN    GENERAL.  77 

in  fevers  of  regular  paroxysms;  for  in  these,  the  pulse  might  in- 
dicate in  many  instances  the  abstraction  of  more  blood,  when  it 
might  be  safely  dispensed  with.  But,  if  in  these  very  fevers, 
there  occurs  strong  local  determination,  and  especially  if  this  be 
to  the  head,  as  becomes  evident  by  head-ache,  or  delirium,  we 
should  bleed  again  and  again,  if  the  force  of  the  disease  con- 
tinue, or  is  but  little  abated;  provided  the  pulse  maintains  a  suf- 
ficient force  and  vigour,  to  justify  the  operation. 

237.  The  circumstances  under  which  we  should  not  bleed,  are 
those,  in  which  the  system  is  depressed  by  the  cold  stage  of 
fever;  or  temporarily  prostrated,  by  excessive  evacuation.     la 
the  first  case,  the  cold  stage  would  be  much  protracted  by  bleed- 
ing ;  and  the  reaction  of  the  system  would  be  much  delayed ;  or 
the  powers  of  the  system  might  so  sink,  by  an  ill-timed  bleed- 
ing, as  to  be  unable  to  react.     In  the  second,  the  powers  of  life 
may  be  so  reduced,  that  a  fatal  syncope  might  follow.     Of  so 
much  consequence  is  it  then,  to  attend  to  the  circumstances  un- 
der which  we  bleed.   The  accidents  we  have  just  noticed,  might 
take  place  in  cases,  where  bleeding  might  again  and  again  be  ne- 
cessary, were  the  system  allowed  to  react,  or  when  not  prevented 
from  reacting,  by  the  injudicious  employment  of  this  remedy. 

C.  Sweating. 

238.  There  is  no  remedy  so  decidedly  popular  for  the  cure  of 
fever,  as  sweating;  and  none,  perhaps,  has  been  more  abused.   As 
the  healthy  solution  of  almost  all  fevers  has  been  effected  by  this 
process  when  allowed  uninterruptedly  to  run  their  course ;  and 
as  almost  all  fevers  of  regular  paroxysms  terminate  by  this  dis- 
charge— it  naturally  suggested  itself  that,  if  we  could  imitate  this 
process,  we  should  sooner,  and  more  certainly  cure  the  disease. 
Accordingly,  from  time  immemorial,  this  mode  of  cure  has  been 
attempted;  but  not  always  with  equal  success.     It  has  always 
been  a  popular  belief  that,  in  proportion  to  the  quantity  evacuated 
by  the  skin,  is  the  efficacy  of  this  process;  than  which  nothing 
can  be  further  from  the  truth. 

239.  This  vulgar  error  has  proceeded  from  not  discriminating, 
between  the  insensible  perspiration,  and  that  collection  of  fluid 
upon  the  surface,  called  sweat.     It  is  not  our  intention  to  enter 
minutely  into  these  differences,  by   giving  their  history  or  by 
inquiring  into  their  causes ;  but  simply  to  state  that,  while  in 
many  instances,  a  pleasant,  soft,  silky  feel  of  the  skin  in  conse- 
quence of  the  insensible  perspiration  being  increased,  shall  re- 
lieve a  patient  in  fever,  a  profuse  and  deluging  sweat,  shall  to- 
tally fail  of  this  end.      In  a  number  of  instances  we  have  known 
an  overwhelming  sweat  to  be  followed  by  a  hard,  rigid  skin,  and 


78  OF    FEVER    IN    GENERAL. 

without  the  smallest  diminution  of  the  force  of  the  arterial  sys- 
tem, or  the  least  abatement  of  the  distressing  and  threatening 
symptoms.  On  the  other  hand,  we  have  seen  the  whole  system 
tranquillized  and  relieved  by  a  gentle  moisture  breaking  out 
either  spontaneously,  or  produced  by  the  exhibition  of  some  pro- 
per remedy  for  this  end.  We  may  therefore  lay  it  down  as  an 
invariable  rule,  as  far  as  our  experience  justifies  us  in  the  asser- 
tion, that  in  no  instance  of  fever,  simply  so  called,*  does  profuse 
sweating  relieve,  as  much  as  gentle  perspiration.  It  follows,  then, 
that  this  evacuation  has  been  in  too  many  instances  indiscreetly 
urged. 

240.  In  employing  remedies  with  a  view  to  promote  perspi- 
ration, (for  this  is  all  that  should  be  attempted,)  we  must  regard 
with  attentive  care,  1st,  the  period;  2d,  the  state  of  the  body  as 
regards  temperature;  and  3d,  the  agents  employed. 

241.  1st.  The  period  of  the  febrile  paroxysm  at  which  we  at- 
tempt its  solution  by  producing  perspiration,  is  a  matter  of  great 
moment;  we  must  not  commence  our  plan   in  the  cold  stage ; 
nor  should  we  be  more  successful  at  the  formation  of  the  hot 
stage,  nor  even  at  its  height,  unless  proper  evacuations  have  so 
much  reduced  the  vigour  of  the  pulse,  as  to  render  the  operation 
of  medicine  probable ;  or  unless  the  fever  itself,  it  be  of  so  mild 
a  grade,  that  an  impression  can  be  made  upon  it  by  the  exhibition 
of  diaphoretics.   It  therefore  follows,  that,  we  should  not  exhibit 
any  one  of  this  class  of  medicines,  while  the  pulse  is  full,  hard, 
and  frequent — for  were  we  to  do  so,  we  should  not  only  be  foiled 
in  our  attempts,  but  have  the  mortification  to  see  every  symptom 
aggravated;  for  there  is  a  "sweating  point"  of  the  arterial  sys- 
tem, as  well  as  a  "  sweating  point"  of  temperature. 

242.  2d.  The  state  of  the  body  as  regards  temperature. — 
From  the  well-conducted  and  conclusive  experiments  of   Dr. 
Alexander,  it  appears  that  the  heat  of  the  body  can  transcend 
the  "sweating  point;"  and  that,   when  this  is  the  case,  it  re- 
quires a  reduction  of  temperature,  before  the  sweating  process 
can  commence.     He  fixes  this  point  at  108°,  but  we  have  reason 
to  believe  this  too  high,  say  100°  or  102°.     It  therefore  follows, 
that  to  procure  perspiration,  the  heat  of  the  body  must  not  ex- 
ceed this  degree  of  temperature;  and  hence  it  is,  that  many  have 
been  defeated  in  their  attempts  by  increasing  the  heat  by  stimu- 
lating drinks,  and  by  additional  bed-clothes,  beyond  the  "sweat- 
ing point."     And  hence  it  is,  that,  a  drink  of  cold  water,  has 
many  times  proved  the  best  diaphoretic,  by  suddenly  bringing 
down,  or  reducing  the  heat  of  the  body  to  the  "  sweating  point ;" 

*  In  acute  rheumatism,  sweating  is  sometimes  highly  useful,  but  not  always; 
but  this  is  a  disease  very  different  from  fevers  arising  from  marsh  effluvia,  or 
other  eauses  capable  of  producing  simple  fever. 


OF    FEVER   IN    GENERAL.  79 

and  that,  by  sponging  the  body  with  cold  water  or  vinegar,  per- 
spiration has  been  immediately  excited.  It  may,  therefore,  be  laid 
down  as  a  rule,  that  all  attempts  to  procure  perspiration  will  be 
unavailing,  if  the  heat  of  the  body  exceed  102°. 

243.  3d.  As  regards  the  agents,  they  must  be  accommodated 
to  the  state  of  the  system  itself — and  this  will  refer  both  to 
arterial  action,  and  temperature.   We  have  already  noticed  that, 
there  is  a  choice  of  period,  in  the  paroxysms;  and  also,  that  re- 
gard must  be  paid  to  the  condition  of  the  pulse;  and  we  will 
now  add,  that,  whenever  the  hot  stage  is  attended  by  a  vigorous 
pulse,  and  strong  local  determination,  especially  to  the  head, 
every  attempt  to  procure  a  diaphoresis  will  not  only  be  unavail- 
ing, but  injurious;  and  that  the  system  must  be  properly  pre- 
pared, (if  we  may  so  express  ourselves,)  by  bleeding,  purging, 
&c.  before  an  attempt  of  this  kind  be  made.     As  a  general  rule, 
when  there  is  considerable  vigour  in  the  system,  the  antimo- 
nial  preparations  will    be   the   most  eligible ;  and  if  accompa- 
nied with  much  heat,  nitre  will  sometimes  be  an  useful  addi- 
tion.* 

244.  If  there  be  but  a  moderate  degree  of  vigour  in  the  pulse, 
or  if  it  be  soft,  opium  is  a  highly  important  drug.     This  medi- 
cine seems  to  merit  a  decided  preference  in  all  the  more  pro- 
tracted forms  of  fever,  or  where  the  powers  of  the  system  have 
been  pretty  much  expended  ;  and  in  all  those  of  weak  action, 
even  in  the  commencement,  provided,  there  be  no  determination 
to  the  head,  to  cause  head-ache,  drowsiness,  or  delirium.     The 
proper  time  for  its  exhibition  is  at  the  early  part  of  the  hot  stage. 
It  should  be  given  in  such  quantities,  and  at  such  intervals  as  to 
make  a  decided  impression;  but  not  so  much  as  to  have  its  nar- 
cotic effects  predominate;  nor  should  the  frequency  of  exhibition 
be  such,  as  to  subject  the  system  to  this  part  of  its  influence.  We 
therefore  hold  it  wrong  to  give  it,  either  in  such  a  dose  or  doses, 

*  The  combination  of  nitre  and  tartar  emetic,  is  sometimes  employed  with 
great  advantage  in  cases,  where  there  is  a  hot  dry  skin;  much  thirst,  and  head- 
ache; and  where  the  pulse  is  yet  too  high  for  the  exhibition  of  opium,  but  not 
sufficiently  so,  as  to  render  blood-letting  proper.  And  it  is  especially  useful, 
when  the  bowels  are  tardy;  as  the  addition  of  a  little  calomel,  gives  great 
efficacy  to  its  power  over  the  bowels;  particularly,  where  it  might  be  objec- 
tionable to  give  a  cathartic  expressly.  The  following  formula  is  one  in  com- 
mon use: — 


R.     Sal.  nitri        -        -        giss. 
Emet.  tart.  '-        -        gr.  j. 


Take  Nitre  or  saltpetre       1J  drachm. 
Tartar  emetic      -      1  grain. 


Calom.  ppt.  gr.  viij.  I  Prepared  calomel       8  grains. 

M.  et  div.  in  viij.  Mix,  and  divide  in  8  parts. 

One  of  these  powders  to  be  given  every  two  hours,  mixed  in  a  little  roasted 
apple,  or  syrup  of  any  kind.  If  they  operate  on  the  bowels  too  much,  they 
must  be  suspended. 


80  OP    FEVER    IN    GENERAL. 

as  will  subject  the  brain  to  its  anodyne  powers;  for  whenever  we 
induce  this  tendency  to  coma,  we  unnecessarily  prostrate  the 
system.  The  powers  of  opium,  when  administered  with  a  view 
to  produce  perspiration,  are  decidedly  augmented  by  the  addi- 
tion of  some  other  substances;  and  perhaps  one  of  the  very  best 
forms,  is  that  of  Dover's  powder.* 

245.  We  have,  however,  seen  cases,  in  which  the  internal  ex- 
hibition of  remedies  have  failed  to  procure  perspiration,  how- 
ever eligible  in  kind,  or  however  faithfully  persevered   in  ;  yet 
it  has  been  quickly  excited,  by  external  applications.  One  of  the 
simplest,  and  at  the  same  time,  one  to  be  most  relied  on  is,  the 
vinegar  vapour.     This  appears  to  be  particularly  successful  in 
those  cases,  where  there  is  a  dry,  hard  skin,  without  excessive 
external  heat — for  we  have  known  it  to  be  a  powerful  auxiliary 
to  opium,  when  there  has  not  been  a  sufficient  or  regular  distri- 
bution of  heat  to  the  surface.   It  should  never,  however,  be  used 
when  the  temperature  is  above  the  "  sweating  point,"  nor  where 
the  external  heat  is  easily  augmented,  by  any  additional  sti- 
mulus. 

246.  In  conducting  the  sweating,  no  inconsiderable  care  is  re- 
quired, that  its  utility  may  not  be  defeated.     We  have  already 
said,  our  aim  should  be,  to  produce  a  gentle  transpiration,  but 
not  a  profuse  sweat.   Therefore  whenever  we  find  it  transcend- 
ing this  condition,  we  should  abate  it,  by  the  removal  of  some  of 
the  covering.   And  when  we  find  this  sweating  is  not  produced, 
pretty  soon  after  the  exhibition  of  medicine;  or  by  external  ap- 
plications, we  should  carefully  examine  the  state  of  heat  of  the 
patient's  skin — if  this  be  very  hot,  we  can  only  induce  perspi- 
ration by  its  reduction;  this  must  be  attempted,  either  by  a  re- 
moval of  the  bed-clothes ;  by  the  use  of  a  large  draught  of  cold 
water,  or  by  sponging. 

247.  The  length  of  time  that  sweating  should  be  kept  up, 
must  depend  very  much  upon  its  quantity;  by  its  effect  on  the 
pulse;  or  the  sensations  of  the  patient.    We  have  noticed  that,  a 
profuse  sweat  is  not  desirable ;  and  therefore,  when  this  happens, 
either  from  the  bad  manner  in  which  it  has  been  conducted,  or 
from  some  peculiarity  of  the  patient,  we  should  endeavour  to 
check  it  by  a  removal  of  some  of  the  bed-clothes;  by  the  admis- 
sion of  cooler  air  into  the  room;  or  by  taking  away  the  external 

*  Recipe  for  Dover's  powder: — 

R.    Pulv.  ipecac.,  Pulv.  opii.,  aa.         ^j. 

Sulphate  of  potass          -        -        3viij.  M. 

Ten  grains  of  this  powder  is  considered  a  dose — it  should  be  mixed  in  a  little 
syrup  or  gruel,  and  the  patient  should  not  drink  any  thing  for  an  hour  after  its 
exhibition. 


OF    FEVER    IN    GENERAL.  81 

means,  if  any  should  have  been  employed  to  excite  it,  and  by 
abstaining  from  warm,  or  hot  drinks. 

248.  Should  the  pulse  be  much  reduced  in  force  and  frequency 
by  this  means,  even  soon  after  the  breaking  out  of  the  perspira- 
tion, we  may  prepare  to  check  it  by  the  plan  already  suggested. 
Or  should  the  patient  become  very  faint,  exhausted,  or  extremely 
restless  under  its  influence,  we  should  not  persist  in  its  continu- 
ance. 

249.  After  the  patient  has  been  subjected  to  the  sweating  pro- 
cess, all  the  clothes  which  surrounded  him  should  be  removed 
and  replaced  by  fresh  linen,  &c.  as  soon  as  he  is  dry    This  is  a 
matter   of  considerable  importance,  and  where  practicable,  it 
should  always  be  complied  with. 

D.  Purging. 

250.  In  fevers  of  almost  every  description,  purging  is  not 
only  useful,  but  in  many,  is  indispensable.     There  exists  con- 
stantly a  want  of  equilibrium  in  the  circulatory  system,  when- 
ever the  body  is  attacked  with  fever — and  the  determination  for 
the  most  part  is,  to  the  brain,  the  liver,  the  spleen,  or  to  the 
lungs;  and  few  remedies  are  found  so  effectual  in  restoring  this 
disturbed  balance,  as  well  chosen,  and  properly  adopted  aperients. 
Besides  the  determinations  just  mentioned,  fecal  matter  in  the 
bowels,  is  constantly  accumulating,  which  it  is  of  much  conse- 
quence to  remove.     Occasionally  there  will  be  a  redundancy  of 
bile;  at  other  times  a  deficiency;  and  we  are  obliged  sometimes 
to  remove  the  one,  or  to  solicit  the  other;  and  both  of  these  ends 
are  answered  by  the  proper  choice,  and  exhibition  of  cathartics, 
of  the  aperient  or  laxative  kind.* 

251.  Purges,  besides  clearing  the  intestines  of  offensive  mat- 
ters, cause  to  be  discharged  into  the  bowels,  a  considerable  quan- 
tity of  the  fluids,  natural  to  these  parts;  and  thus  serve  the  double 
purpose  of  removing  the  fecal  contents,  and  evacuating  at  the 
same  time  from  the  general  system.     For  effecting  these  pur- 
poses however,  some  cathartics  are  much  more  valuable  than 
others ;  consequently  there  is  a  considerable  choice.      We  shall 
not  enter  more  fully  into  a  detail  of  them  than  we  have  already 
done ;  designing,  in  the  treatment  of  each  disease,  to  point  out 

*  Cathartics,  signify  such  medicines  as  quicken  the  peristaltic  motion,  there- 
by inducing  a  more  free  evacuation  of  the  bowels.  But  as  this  class  of  medi- 
cines differ  very  much  in  the  capacity  to  provoke  this  increase  of  motion  of 
the  intestines,  they  have  been  very  properly  divided  into  laxatives  or  aperients, 
and  purgatives.  The  former  are  such  as  act  gently  upon  the  bowels,  as  castor 
oil,  magnesia,  rhubarb,  neutral  salts,  as  Epsom  or  Glauber,  &c.  The  latter 
are  such,  as  act  with  more  violence  upon  the  bowels,  as  calomel,  jalap, 
senna,  &c. 

11 


82  OP    FEVER    IN    GENERAL. 

the  proper  cathartics,  as  these  remedies  may  be  necessary  for  the 
particular  disease  under  consideration. 

252.  The  management  of  cathartics  must  be  regulated,  1st, 
by  the  state  of  the  system  in  general,  and  of  the  bowels  in  par- 
ticular ;  they  are  indicated  when  the  system  maintains  its  general 
vigour,  and  where  the  bowels  are  still  loaded,  or  not  sufficiently 
cleansed — the  pulse  will  direct  in  the  one  instance,  and  the  ap- 
pearance of  the  evacuations  in  the  other.   The  regular  inspection 
therefore,  of  these  discharges  is  a  matter  of  much  moment ;  and 
should  never  be  neglected  by  those  who  may  have  the  care  of 
the  sick — for,  it  is  not  always  sufficient  that  the  patient  should 
frequently  require  the  pan ;  for  these  calls  may  be  for  the  dis- 
charge of  thin,  watery  fluids,  and  not  for  the  evacuations  of  feces — 
and  sometimes  such  is  the  operation  of  purgative  medicines, 
that  they   will   excite   the  bowels   to   frequent   action,    with- 
out removing  the   offensive  matters   contained  in  them.     On 
this  account  we  recommend  the  regular  inspection  of  these  dis- 
charges, that  we  may  not  be  deceived  in  a  matter  of  such  mo- 
ment.  (See  par.  93,  &c.)     There  is  sometimes  a  strong  popular 
prejudice  against  purging,  that  we  would  gladly  remove;  namely, 
that  they  are  "very  weakening.3'     Purging,  like  every  other 
evacuation,  may  be  carried  too  far ;  and  then  with  strict  pro- 
priety it  may  be  said  they  are  "weakening" — but  this  is  only 
the  abuse,  or  mal-administration  of  the  remedy.     In  many  cases 
of  fever,  the  patient  is  so  far  from  being  weakened  by  being 
purged,  that  he  is  absolutely  strengthened  by  it.*     And  again, 
it  is  frequently  said,  when  these  medicines  are  about  to  be  ad- 
ministered, that  they  "cannot  be  necessary,  for  there  is  nothing 
inside  of  the  patient  to  bring  away ;"  and  as  a  proof  of  this,  they 
will  declare  "  the  patient  has  eaten  nothing  for  a  number  of  days." 

253.  This  popular  language  and  feeling,  must  be  disregarded, 
if  we  do  not  mean  to  injure  the  patient;  especially,  where  atten- 
tion has  been  paid  to  the  quantity  and  nature  of  the  discharges; 
and  where  we  are  convinced,  from  these  inspections,  that  much 
remains  to  be  removed.     For  we  have  frequently  seen,  after  the 
purging  process  has  been  continued  for  a  considerable  time,  and 
where  the  friends  of  the  patient  were  convinced  there  was  "  no- 
thing inside,"  large,  hard,  and  fetid  evacuations  have  succeeded 
those  "watery  stools,"  and  the  patient  has  been  almost  imme- 
diately restored  to  health.     We  could  say  much  upon  this  im- 
portant subject,  but  our  limits  will  not  permit  us. 

•  This  has  been  repeatedly  exemplified  in  yellow  fever.  We  have  known 
patients  nearly  faint,  when  labouring  under  this  disease,  upon  being  merely 
put  in  an  upright  position;  yet  after  a  free  purging,  and  other  evacuations, 
they  have  been  able  to  get  out  of  bed,  and  walk  the  floor.  Now,  were  these 
remedies  directly  weakening,  the  contrary  of  this  should  have  happened. 


OF    FEVER    IN    GENERAL.  83 

254.  2d.  Attention  should  be  paid  to  the  time  they  are  admi- 
nistered— they  should  not  be  given,  (unless  it  would  be  the  loss 
of  precious  time  to  procrastinate,)  so  as  to  interfere  with  the 
night's  rest  of  the  patient ;  nor  should  they  be  used,  so  that  they 
shall  interfere  with  the  "sweating  period  of  fever;"  nor  with- 
out previous  preparation  by  bleeding,  in  the  more  concentrated 
form  of  the  disease. 

255.  3d.  They  should  not  be  given  in  the  decline  of  fevers, 
where  the  patient  is  rapidly  convalescing,  lest  they  produce  a 
relapse — but  this  is  not  intended  to  prevent  proper  attention  to 
the  bowels  at  this  time;  for  costiveness  might  be  as  injurious  as 
purging.     Nor  must  we  use  them  when  the  patient  is  much  ex- 
hausted by  colliquative  diarrhoea :  nor  near  the  decline  of  a  fe- 
brile paroxysm. 

256.  4th.  The  operation  should  be  so  managed,  that  the  patient 
need  not  unnecessarily  expend  his  strength  in  complying  with 
its  demands — he  should,  therefore,  never  be  permitted  to  get 
out  of  bed  for  this  purpose,  when  he  is  so  weak  as  to  incur  the 
risk  of  fainting,  or  of  even  being  much  exhausted.     A  bed  pan 
should  always  be  used ;  and  although  it  may  at  first  be  a  little 
awkward  to  the  patient,  a  little  practice  would  reconcile  him  to 
it.     (Seep.  44.) 

257.  5th.  The  patient  should  be  so  protected  by  clothing, 
when  obeying  these  calls  in  cool  or  cold  weather,  that  he  may 
run  no  risk  of  taking  cold,  or  provoking  chill — on  this  account 
also,  we  should  guard  against  his  getting  out  of  bed,  when  it  is 
practicable  to  confine  him — he  should  have  his  stockings  drawn 
on,  and  a  pair  of  warm  slippers  ready  for  him  to  step  into — and 
he  should  also  be  carefully  covered  with  a  blanket,  during  the 
time  he  is  sitting  upon  the  pan. 

E.  Of  Blisters. 

258.  One  of  the  most  common  resources  in  fevers  of  every 
description,  is  blistering;  nor  is  any  remedy  more  abused;  be- 
cause no  one  is  so  empirically  prescribed.     The  employment  of 
blisters,  in  the  cure  of  fevers,  must  be  governed  by  strict,  and 
decided  laws,  or  very  certain  injury  will  ensue.     Therefore,  in 
using  them,  reference  must  be  had,  1st,  to  the  period  of  the  dis- 
ease, or  rather  to  the  state  of  the  arterial  system;  2d,  to  the  part 
to  which  they  are  applied;  3d,  to  the  duration  of  their  applica- 
tion ;  4th,  to  the  peculiarities  of  the  patient,  as  regards  the  more 
remote  effects  of  this  remedy. 


84  OF    FEVER    IN    GENERAL. 


a.   Of  the  Period  of  the  Disease,  or  State  of  the  Arterial 

System. 

259.  The  discrepant  accounts  that  we  meet  with  in  authors, 
of  the  febrifuge  effects  of  the  blisters,  have  arisen,  we  are  dis- 
posed to  believe,  from  the  little  regard  paid  to  the  state  of  the 
system  by  those  who  look  upon  such  application  as  mischievous, 
at  the  time  of  their  application;  while  they  are  recommended  in 
terms  of  the  strongest  confidence  by  others,  who  have  been  more 
attentive  to  this  great  practical  distinction.   It  is,  therefore,  justly 
inferable,  that  both  parties  were  right  as  regarded  effects ;  but 
only  one  was  right  as  regarded  the  usefulness  of  blisters ;  as  only 
one  was  directed  by  principles,  in  their  use. 

260.  It  is  now  well  ascertained,  that  blisters  have  as  decided, 
and  as  well  characterized  a  period  for  application,  as  blood-letting, 
cathartics,  or  emetics;  and  when  used  at  improper  times,  they 
will,  like  either  of  the  remedies  just  named,  do  mischief.     It  is 
therefore  important,  that  the  pulse  he  in  a  proper  condition  ;  that 
is,  of  very  moderate  force,  at  the  time  of  their  application;  for 
if  it  be  not  in  a  reduced  state,  blisters  will,  like  wine  and  other 
stimuli,  increase  the  state  of  arterial  action.  The  blistering  point 
therefore  always  means,  when  the  arterial  force  is  rather  below 
par,  as  it  is  termed.     Or  in  other  words,  where  the  artery  can 
be  easily  compressed,  or  is  soft.     When  employed  in  this  state 
of  the  system,  we  are  very  sure  they  will  do  no  mischief;  but, 
on  the  contrary,  we  have  every  reason  to  anticipate  a  favourable 
result,  if  the  case  has  been  a  fair  one  for  their  application  ;  for  it 
must  be  recollected,  that  blistering  will  not  relieve  every  state  of 
disease,  that  may  be  attended  by  a  soft  or  yielding  pulse. 

b.   Of  the  Part  to  which  they  are  Applied. 

261.  It  is  a  matter  of  some  moment  to  select  the  proper  seat 
for  the  blister  or  blisters.     Therefore,  as  a  general  rule,  we  may 
say,  that  in  such  fevers  as  are  not  marked  by  local  affections,  as 
in  pleurisy,  inflammation  of  the  liver,  or  other  partial  inflamma- 
tions, that  the  extremities  are  the  best  locations  for  them.     On 
the  calves  of  the  legs,  when  the  circulation  in  these  parts  is  not 
too  languid,  as  may  be  determined  by  their  coldness  and  insen- 
sibility; and  on  the  inside  of  the  thighs,  when  this  is  the  case. 
The  application  to  the  arms  may  be  regulated,  by  the  same  state 
of  the  parts ;  to  the  forearm,  when  its  sensibility  is  sufficient  for 
the  purpose ;  and  above  the  elbow,  when  it  is  not. 

262.  It  will  not  be  necessary  to  extend  the  subject  here,  as 
we  have  already  adverted  to  it,  at  page  45 ;  and  especially  as  we 


OF    FEVER    IN    GENERAL.  86 

shall  in  each  separate  disease,  point  out  the  part  to  which  they 
shall  be  applied,  when  these  remedies  are  indicated. 

263.  In  remittent  and  intermittent  fevers,  blisters  are  almost 
always  applied  to  the  extremities ;  and  are  indicated,  whenever 
it  is  necessary  to  make  a  strong  impression  upon  the  system,  for 
the  purpose  of  procuring  a  more  decided  remission,  or  a  more 
distinct  intermission,  after  the  force  of  the  pulse  has  been  abated, 
by  antecedent  remedies ;  or  is  already  so,  by  the  type  of  the 
fever  itself. 

c.  Of  the  Duration  of  their  Application. 

264.  In  general,  blisters  are  permitted  to  remain  on  twelve 
hours.     If  they  have  not  produced  their  effect  in  that  time,  an 
hour  or  two  more  should  be  allowed  them.   But  if  the  inquietude 
of  the  patient,  or  other  signs,  give  evidence  that  they  have  drawn 
at  an  earlier  period,  they  may  be  examined  sooner,  and  dressed, 
if  they  have  performed  their  office.     Indeed,  it  is  found  in  most 
instances,  that  it  is  only  necessary  to  excite  the  vesicating  in- 
flammation; and  this  takes  place  much  earlier  than  is  commonly 
imagined ;  and  especially,  with  delicate  skins,  as  in  most  females, 
and  in  children.     When  this  action  is  excited,  be  this  after  a 
longer  or  shorter  period,  the  blister  should  be  removed,  and  the 
part  covered  with  a  plaster  of  ung.  Basil,  flav.,  which  will  be 
soon  followed  by  satisfactory  vesication. 

d.    Of  the  Peculiarities  of  the  Patient  as  regards  their 
remote  effect. 

265.  We  have  seen  several  instances  of  adults  who  could  not 
bear  the  irritation  of  a  blister,  without  the  most  exquisite  pain, 
as  well  as  the  most  manifest  aggravation  of  existing  symptoms. 
In  such  cases,  we  must  yield  to  the  idiosyncrasy,  by  removing 
these  applications;  for  no  possible  good  can  result  from  a  con- 
tinuance.    Others  are  so  liable  to  severe  stranguary  upon  every 
occasion  of  their  application,  that  we  should  not  insist  upon  their 
employment,  but  when  compelled  by  the  severest  necessity. 
But  this  will  rarely  happen  if  the  plan  just  suggested  be  followed. 

F.   Tonics. 

266.  There  is  no  dread  in  fear  so  universal  as  that  of  weak- 
ness; nor  is  there  a  circumstance  connected  with  disease,  so  se- 
dulously attempted  to  be  guarded  against;  nor  is  there  one  that 
has  been  so  uniformly  mischievous.    Under  the  influence  of  this 
apprehension,  proper  remedies  are  withheld,  and  their  places  sup- 


86  OV   FEVER    IN    GENERAL. 

plied  by  such  as  are  injurious,  because  the  patient  is  supposed  to 
be  "too  weak"  to  bear  the  appropriate  ones;  and  consequently, 
that  he  absolutely  requires  the  others.  Hence  the  too  early  and 
mischievous,  or  perhaps  fatal  use,  of  improper  diet  and  drinks, 
and  the  injudicious  administration  of  tonics.  We  are  of  opinion, 
that  in  our  climate,  this  class  of  medicines  should  be  exhibited 
with  great  caution,  as  they  have,  in  very  many  instances, 
contributed  from  their  ill-timed  use,  to  protract  disease,  created 
others,  or  have  destroyed  the  patient.  To  the  too  early  use  of  the 
bark,  one  of  the  best  known  and  most  celebrated  tonics  we  have, 
we  may  but  too  often  attribute  the  visceral  obstructions  which 
follow  fever;  and  from  its  too  early  employment,  intermittents 
have  often  been  rendered  more  intractable,  or  have  been  con- 
verted into  other  more  obstinate  or  dangerous  diseases.  Let  me 
therefore  caution  against  all  unnecessary  fears  for  the  strength  of 
the  patient;  and  the  too  early  use  of  tonics. 

267.  Against  the  too  early  administration  of  bark,  we  can 
hardly  recommend  too  much  caution  ;  nor  do  we  know,  in  ade- 
quate terms,  how  to  warn  against  a  popular  delusion  that  has  been 
the  death  of  thousands.     We  here  allude  to  certain  symptoms 
common  to  most  fevers,  (when  a  little  protracted,  or  when  in 
their  early  stage,  bleeding  and  purging,  have  either  been  alto- 
gether neglected,  or  but  inadequately  performed,)  such  as  a  dry, 
brown  tongue;  flushed  face;  quick  pulse;  red  and  scanty  urine ; 
dark  offensive  stools ;  dry  skin ;  black  lips;  high  delirium;  drow- 
siness or  stupor;  trembling  or  unsteady  action  of  the  arms  when 
about  to  be  used,  &c.     These  with  many  practitioners,  are  look- 
ed upon  as  signs  of  typus ;  and  for  the  relief  of  which,  bark, 
wine,  nay,  the  whole  list  of  stimulants,  are  put  into  immediate 
and  fatal  requisition.     Under  such  circumstances,  with  even  a 
pretty  decided  remission,  neither  the  bark  nor  any  other  sti- 
mulant is  proper.     When  we  treat  of  typhus,  we  shall  have  oc- 
casion to  advert  to  this  bad  and  dangerous  practice.  * 

268.  Of  tonics,  there  is  a  great  variety,  some  decidedly  pre- 
ferable to  others ;  but  the  choice  of  them  in  each  individual  case 
where  indicated,  cannot  be  pointed  out  here.     We  shall,  there- 
fore, as  we  proceed  in  the  history  and  cure  of  diseases,  direct 
the  substances  of  this  class  the  most  proper  to  be  employed,  in 
the  individual  case  that  may  require  them. 

269.  Having  thus  spoken  of  fever,  and  its  cure  in  general,  we 
shall  proceed  to  consider  fevers  in  particular;  and  first  of 

•  See  Chapter  on  Continued  Fever  and  Typhus. 


INTERMITTENT    FEVER.  87 


SECT.  I. — INTERMITTENT  FEVER. 

270.  An  intermittent  is  that  state  of  fever  which  consists  of 
distinct  paroxysms;  with  a  state  of  apyrexia,  or  intervals  which 
are  perfectly  free  from  fever.     This  fever  receives  a  name  from 
the  different  periods  at  which  its  paroxysms  or  its  fehrile  states 
return.   As,  quotidian,  if  the  renewal  of  the  paroxysm  be  every 
day;  a  tertian,  if  every  other  day;  a  quartan,  if  every  fourth 
day,  or  after  the  lapse  of  seventy-two  hours,  &c.  &c. 

271.  This  fever  is  supposed  for  the  most  part  to  arise  from 
marsh  miasma,*  and  is  most  frequent  in  the  spring,  then  termed 
vernal,  and  in  the  fall,  then  called  autumnal,  intermittents.  The 
latter  is  the  more  common  and  the  severer,  of  the  two. 

272.  They  commence  by  a  chill  of  greater  or  less  severity, 
which  lasts  a  longer  or  shorter  time,  according  to  circumstances. 
The  chill  is  followed  by  heat  of  more  or  less  intensity  ;  and  is 
occasioned  by  what  is  called,  the  "  reaction  of  the  system  ;" 
this  reaction,  or  hot  stage,  terminates  after  a  certain  duration,  by 
sweat — and  when  this  last  symptom  subsides,  the  patient  is  left 
apparently  free  from  disease,  until  the  period  of  twenty-four 
hours  from  the  commencement  of  the  previous  chill  comes  round; 
and  then  the  attack  is  renewed,  if  it  be  of  the  quotidian  type. 
In  this  form,  the  interval  is  short;  sometimes  not  exceeding  four 
hours.     In  the  other  forms,  the    intervals  are  proportionably 
longer. 

273.  The  paroxysm  of  an  intermittent  is  divided,  therefore, 
into  three  stages;  1st,  the  cold;  2d,  the  hot;  3d,  the  sweating 
stages. 

274.  Before  the  first  stage  takes  place,  the  patient  for  the 
most  part  feels  languid  and  weak ;  is  indisposed  to  motion ;  is  prone 
to  stretch  and  yawn,  and  generally  has  a  complete  aversion  from, 
food.     The  whole  body  becomes  pale,  and  evidently  diminished 
in  bulk,  especially  the  extremities;  for  rings  will  oftentimes  fall 
from  the  fingers.     Sometimes  the  cold  sensation  is  intense,  and 
the  patient  will  shake  severely;  at  other  times,  the  coldness  is 
more  moderate,  and  some  trifling  trembling  is  all  that  is  experi- 
enced. 

275.  After  this  sense  of  coldness  has  been  endured  for  some 
time,  its  intensity  begins  to  abate  gradually,  and  is  eventually 

*  Of  this  agent,  Dr.  Johnson,  (Influence  of  Tropical  Climates,  &c.)  very 
properly  observes,  "the  term  marsh,  is  not  so  proper  as  vegeto-animal  effluvium 
or  miasma;  since  experience  and  observation  have  proved,  that  these  febrile 
exhalations  arise  from  the  summits  of  mountains  as  well  as  from  the  surface  of 
swamps.  The  mountains  of  Ceylon,  covered  with  woods  and  jungle,  and  the 
vast  ghauts  themselves,  give  origin  to  miasmata,  that  occasion  precisely  the  same 
fever  as  we  witness  on  the  marshy  plains  of  Bengal." 


88  INTERMITTENT    FEVER. 

succeeded  by  a  glow  that  spreads  itself  successively  over  the 
whole  body;  and  after  a  small  interval,  is  converted  into  a  heat 
of  greater  or  less  intensity;  the  face  and  other  parts  of  the  body 
redden;  the  skin  becomes  dry;  the  thirst  intense;  the  head-ache, 
anxiety,  and  restlessness  excessive;  the  tongue  is  furred;  the 
pulse  frequent,  and  for  the  most  part  hard  and  full.  This  stage 
is  sometimes  attended  with  stupor,  delirium,  convulsions,*  coma, 
or  apoplexy. 

276.  After  the  hot  stage  has  continued  its  period,  a  moisture 
is  discoverable  upon  the  forehead,  which  gradually  spreads  it- 
self over  the  whole  surface  of  the  body,  and  eventually  is  con- 
verted into  a  sweat — when  this  takes  place,  there  is  almost  al- 
ways an  abatement  of  the  most  distressing  symptoms;  and  after 
a  while,  most  of  the  functions  are  restored  to  their  natural  state, 
and  little  inconvenience  is  experienced,  except  debility.    In  this 
stage  it  is  well  to  remark,  that  the  urine  deposites  a  sediment; 
whereas  in  the  former  stage,  it  is  almost  always  colourless.   The 
entire  series  of  symptoms  just  enumerated,  is  again  and  again  re- 
peated ;  and  the  interval  between  each,  depends  upon  the  speci- 
fic type  of  the  intermittent. 

277.  The  chance  of  recovery  is  in  proportion  to  the  mildness 
of  the  symptoms ;  the  shortness  of  the  paroxysms ;  and  the  free- 
dom from  complaint  in  the  intervals.     Agues  rarely  destroy  by 
true  inflammatory    determinations    to   the  head  or    the  chest. 
When  they  are  fatal,  it  is  for  the  most  part  by  inducing  disease 
in  other  parts  of  the  body,  as  in  the  liver  or  spleen  ;  or  by  a  drop- 
sical affection  of  the  abdomen.     They  are  more  fatal  in  hot,  than 
in  cold  climates. 

278.  In  the  cure  of  intermittents  there  are  three  principal  ob- 
jects to  be  attempted  ;  1st,  to  shorten  the  fit ;  2d,  to  interrupt  the 
return  of  it;  3d,  to  prevent  the  recurrence  of  the  disease,  after 
it  has  ceased  a  certain  time. 

279.  To  fulfil  the  first  object,  the  application  of  warm  things 
to  the  whole  body ;  but  to  the  feet,  legs,  and  pit  of  the  stomach, 
in  particular,  is  of  primary  consequence — this  may  be  aided  by 
draughts  of  warm  baum  tea,  lemonade,  or  common  tea.     A  jug 
of  warm  water  to  the  pit  of  the  stomach  is  not  only  very  grate- 
ful, but  is  very  efficient  in  shortening  the  cold  fit.     Dr.  Trotter 
found  thirty  drops  of  laudanum  of  great  use  in  shortening  the 


*  We  have  lately  attended  a  young  gentleman  of  twelve  years  of  age,  in 
•whom  the  cold  stage  of  an  intermittent  was  ushered  in  by  a  violent  convulsion, 
which  lasted  some  minutes — it  was  followed  by  a  stupor  of  some  hours,  which 
however  yielded  to  a  bleeding  from  the  arm,  and  a  leeching  from  the  temples, 
together  with  pretty  active  purging.  The  paroxysms  were  suspended  by 
Fowler's  solution — there  was  no  repetition  of  the  convulsion — this  young  gen- 
tleman was  habitually  liable  to  head-ache  from  an  early  period  of  his  life. 


INTERMITTENT   FEVER.  89 

cold  stage  of  intermittents — it  was  given  as  soon  as  the  patient 
could  discover  any  sign  of  its  approach;  and  if  in  fifteen  minutes 
after  its  exhibition,  a  sensation  of  warmth  was  not  felt,  the  dose 
was  repeated.  This  plan  was  pursued  for  several  periods  con- 
secutively at  the  time  of  expected  attack;  this  being  regulated 
by  the  type  of  the  ague — if  a  quotidian,  every  day ;  if  a  tertian, 
every  other  day,  and  so  on.  This  method  of  arresting  the  pa- 
roxysm of  an  intermittent,  is  used  by  several  respectable  prac- 
titioners of  our  city,  and  with  which  they  feel  well  satisfied.  It 
must  however  be  supposed,  that  where  success  attends  this  prac- 
tice, that  the  disease  is  of  a  mild  character,  and  without  much 
evidence  of  cerebral  determination.  In  agues  of  long  standing, 
or  in  enfeebled  constitutions,  laudanum  would  be  much  more 
likely  to  succeed,  than  in  intermittents  of  an  opposite  character 
— indeed  we  are  of  opinion  that  it  should  never  be  employed 
without  sufficient  depletion  by  blood-letting  or  purging  having 
been  previously  employed. 

280.  After  the  hot  stage  commences,  we  should  endeavour  to 
abridge  its  duration  as  much  as  possible — for  this  purpose  the 
warm  applications  must  be  removed — the  bed-clothing  diminish- 
ed— cool  air  admitted — cool  or  cold  drinks  administered — and 
should  much  head-ache  be  present,  the  pulse  active  and  firm, 
much  relief  will  be  experienced  by  the  loss  of  a  few  ounces  of 
blood.     In  prescribing  blood-letting  in  ague,  we  do  not  offer  it 
as  a  remedy  that  will  of  itself  cure  the  disease  ;  but  we  can  from 
very  considerable  experience  recommend  it  as  one,  that  affords 
almost  immediate  relief  in  most  cases ;  and  in  all,  where  its  use 
is  justified  by  the  pulse,  it  shortens  the  hot,  and  fastens  the 
sweating  stage;  it  moreover  prepares  the  system  in  a  very  cer- 
tain manner,  for  the  exhibition  of  tonics.     The  importance  of 
the  last  effect,  is  of  much  moment;  but  we  fear  it  is  not  suffi- 
ciently appreciated — had  this  remedy  been  more  frequently  re- 
sorted to,  we  think  that  the  duration  of  agues  and  their  melancholy 
suite,  would  have  been  much  more  rare. 

281.  Opium  during  the  hot  stage  is  highly  extolled, and  boldly 
recommended  by  several  high  authorities;  especially  Dr.  Lind. 
In  this  particular  district  of  country  we  are  of  opinion,  it  should 
be  given  with  much  caution,  especially  when  bleeding,  purging, 
and  other  depleting  remedies,  have  not  preceded  its  use.     We 
have  seen  good  effects  from  this  remedy  after  a  sufficient  bleed- 
ing, and  would  never  hesitate  to  exhibit  it,  where  this  evacua- 
tion had  diminished  the  force  of  the  pulse;  and  where  there  was 
no  marked  determination  to  the  head.     In  the  warmer  parts  of 
our  country,  we  need  not  perhaps  be  so  cautious — as  there,  the 
disposition  to  inflammatory  diathesis  is  less ;  and  opium  can  be 
given  both  earlier,  and  with  greater  freedom.     These  districts 

12 


90  INTERMITTENT    FEVER. 

resemble  more  the  climates  in  which  Dr.  Lind  found  opium  so 
useful. 

282.  If  then  the  pulse  be  moderately  soft,  either  from  the  dis- 
ease being  unattended  by   much  inflammatory   action  ;  or  from 
previous  depletion,  a  grain  of  opium  with  a  quarter  of  a  grain  of 
the  tartrite  of  antimony,  may  be  given  at  the  commencement  of 
the  hot  fit;  and  if  it  act  favourably,  it  will  procure  a  free  perspi- 
ration over  the  whole  body — but  if  instead  of  this,  we  find  the 
hot  stage  protracted ;  or  the  symptoms  aggravated,  it  should  not 
be  again  given,  until  the  activity  of  the  blood-vessels  is  more 
effectually  subdued. 

283.  It  may  not  be  amiss  to  say,  that  the  epidemic  character 
of  intermittents  should  always  be  consulted,  when  we  propose 
to  use  opium  in  any  shape  ;  for  it  is  one  of  those  remedies  which 
has  a  very  decided  agency  upon  the  nervous  system,  and  when 
exhibited  in  any  acute  disease,  without  immediate  benefit,  it 
rarely  fails  to  do  harm — therefore,  the  influence  of  the  epidemic 
upon  the  force,  and  vigour  of  the  pulse,  must  always  be  taken 
into  consideration.     And  as  a  general  rule  we  may  safely  de- 
clare, that  the  usefulness  of  opium  in  arresting  the  paroxysms 
of  intermittents,  will  be  almost  in  proportion  to  the  reduction  of 
the  pulse. 

284.  Should  pain  in  the  side,  or  any  other  local  affection  ac- 
company this  disease,  much  relief  will  be  found  from  cupping, 
or  blistering;  and  should  cough  attend,  fifteen  or  twenty  drops 
of  laudanum  at  bed-time  will  be  found  very  useful.* 

285.  When  sweat  breaks  out,  it  should  be  gently  encouraged 
by  mild  warm  drinks;  but  it  is  never  necessary  to  force  a  pro- 
fuse sweat. 

286.  Secondly,  to  prevent  the  return  of  the  Jit.     This  is  a 
most  important  object,  and  is  attempted  in  two  ways;  first  by 
the  exhibition  of  some  remedy,  which  shall  by  its  immediate  ac- 
tion, prevent  the  febrile  one  taking  place.     Very  many  articles 
have  been  proposed  to  fulfil  this  intention ;  but  it  would  be  use- 
less to  repeat  them.     They  may  now  be  considered  as  confined 

*  Intermittents,  within  the  last  few  years,  have  been  more  extensively  epi- 
demic than  formerly;  and  each,  seems  to  be  marked  by  its  own  peculiarities. 
Sometimes  it  is  accompanied  by  pleuretic,  or  pneumonic  symptoms;  and  these 
almost  constantly  oblige  us  to  vary  the  treatment;  for  the  local  affections,  are 
pretty  sure  to  interrupt  the  regular,  and  common  routine  of  treatment.  Thus, 
if  pleuretic  symptoms  show  themselves,  we  are  necessitated  to  bleed  from  the 
arm,  or  to  cup,  leech,  or  blister  the  affected  side,  before  bark,  or  other  tonics 
can  be  given.  If  cough  accompany,  it  also  interferes  with  the  use  of  tonics, 
especially  bark;  unless  the  cough  be  purely  paroxysmal,  like  the  chill  itself; 
as  happened  in  very  many  of  the  intermittents  of  the  fall  of  1828.  In  these 
cases  the  quinine;  or  Wetherill's  extract  of  bark  was  as  certain  to  stop  the 
cough,  as  it  was  to  interrupt  the  febrile  paroxysm  itself. 


INTERMITTENT    FEVER.  91 

to  emetics,  and  opium.  1st,  if  an  emetic  be  exhibited  about  an 
hour  before  the  expected  chill,  it  will  sometimes  prevent  its  oc- 
currence— when  then,  there  is  no  peculiarity  in  the  constitu- 
tion of  the  patient,  that  would  prevent  the  employment  of  the 
emetic ;  as  when  there  is  no  great  determination  to  the  head,  as 
is  evidenced  by  considerable  head-ache,  and  red  eyes,  this  re- 
medy may  be  used  with  a  prospect  of  success,  especially  if  much 
nausea,  and  bilious  throwing  up,  attend  the  disease.*  And 
should  it  fail  in  this  intention,  it  will  be  at  least  useful  as  an  eva- 
cuant.  We  could  therefore  recommend  its  employment  in  the 
commencement  of  the  disease,  if  its  form  be  a  very  mild  one, 
but  not  otherwise;  for  if  the  chill  be  of  long  duration,  and  the 
reaction  or  the  hot  stage  violent,  an  emetic  should  not  be  used; 
particularly  if  head-ache,  or  delirium  attend;  or  if  a  complete 
solution  of  the  fever  does  not  take  place  by  the  hot  stage  termi- 
nating in  a  general,  and  sufficiently  copious  perspiration.  2d, 
opium,  when  given  in  a  proper  quantity,  and  under  proper  cir- 
cumstances, is  sometimes  successful  in  preventing  the  accession 
of  an  intermittent;  but  of  this  we  have  already  spoken.  (Par.  279.) 

287.  The  second  mode,  is  by  the  use  of  such  remedies  as 
make  an  impression,  during  the  interval.     These  are  classed 
under  the  general  head  of  tonics.    The  most  celebrated  of  these, 
is  the  Peruvian  bark.    This  medicine  is  given  in  a  great  variety 
of  forms,  and  in  very  different  doses;  but  it  is  now  well  ascer- 
tained, that  there  is  too  much  fancy  exercised  in  varying  the 
form  ;  and  very  little  or  no  advantage  in  excessive  doses.   When 
given  in  drachm  doses,  it  has  been  more  successful,  than  when 
extended  to  two,  three,  or  four. 

288.  We  mention  the  bark,  and  its  dose,  because  some  prefer 
it  in  substance,  to  the  sulphate  of  quinine,  which  has  almost  al- 
together superceded  it.     We  do  not,  however,  cherish  this  pre- 
dilection for  the  bark  in  substance — on  the  contrary,  we  could 

*  It  is  commonly  supposed,  if  sickness  or  a  disposition  to  vomit  attend  the 
course  of  the  paroxysm,  that  it  is  caused  by  bile,  or  some  other  crude  sub- 
stance in  the  stomach;  and  that  this,  clearly  indicates  the  necessity  of  an 
emetic;  but  as  this  may  lead  to  great  error  in  practice,  it  is  well  to  observe, 
that  mere  nausea,  even  with  a  discharge  of  some  fluid  from  the  stomach,  does 
not  prove  the  propriety  of  an  emetic;  but  on  the  contrary,  it  may  be,  and  is 
very  often  injurious.  If  what  is  discharged  from  the  stomach  be  really  bile;  that 
is,  a  pure  bitter,  yellow  substance,  a  few  grains  of  ipecacuhananiay  be  useful. 
But  if  the  substance  be  thin,  watery,  and  nearly  tasteless,  it  will  be  injurious. 
We  would  therefore  lay  it  down  as  a  general  rule,  that  the  antimonial  emetic 
is  rarely  as  safe,  even  where  there  is  strong  evidences  of  bile,  as  the  ipeca- 
cuhana  in  fevers  of  high  action,  or  of  strong  paroxysms.  The  reason  of  this  is 
at  once  obvious,  (if  the  most  modern,  and  approved  pathology  of  fevers  be  ad- 
mitted, or  if  any  reliance  can  be  placed  upon  experience,)  namely,  that  they 
are  very  often  caused  by  an  irritation  or  inflammation,  of  the  mucous  mem- 
brane of  the  stomach. 


92  INTERMITTENT    FEVEft. 

wish  it  were  entirely  abandoned,  as  the  quinine,  (creteris  pari- 
bus,)  is  equally  certain,  to  say  the  least ;  and  is,  unquestionably, 
much  more  acceptable  to  the  palate,  and  to  the  stomach.  One 
grain  of  the  quinine  is  equal  to  one  drachm  of  the  bark  in  sub- 
stance. It  is  best  administered  in  solution;  and  may  be  prepared 
as  follows: — Sixteen  grains  of  the  quinine,  four  drops  of  sul- 
phuric acid;  two  drachms  of  powdered  gum  Arabic;  and  three 
drachms  of  sugar,  are  to  be  dissolved  in  two  ounces  of  water — 
of  this,  a  tea-spoonful  is  to  be  given  every  hour,  while  free  from 
fever.*  We  have  been  much  in  the  habit  of  late  of  employing 
Wetherill's  extract  of  bark.  This  preparation  contains  the  qui- 
nine in  the  state  of  a  super-sulphate,  combined  with  the  whole 
of  the  extractive  matter  of  the  cinchona.  It  is  more  certain  in 
arresting  the  paroxysms  than  the  sulphate  of  quinine,  if  our  ob- 
servations have  not  grossly  deceived  us ;  and  the  disposition  to 
the  recurrence  of  them,  seems  to  be  much  lessened. 

289.  It  is  usually  prescribed  in  doses  of  one  grain  in  the  form 
of  a  pill;  one  is  given  every  hour,  while  free  from  fever;  for, 
like  the  quinine,  this  is  the  time  for  its  exhibition. 

290.  After  suitable  evacuations,  by  purgatives,  and  bleeding, 
(or  an  emetic  if  it  has  been  thought  adviseable,)  and  where  there 
is  distinct,  and  decided  intermissions,  we  should  commence  with 
the  bark  or  quinine,  as  soon  as  the  paroxysm  has  completely 
subsided ;  or  in  other  words,  when  there  is  no  longer  any  fever 
remaining.     It  is  too  common  to  order  the  bark,  as  soon  as  the 
sweating  declines;  and  mischief  many  times  has  resulted  from 
obeying  it;  for  very  often  there  is  still  remaining  a  vestige  of 
fever,  even  after  the  perspiration  has  gone  off.  The  pulse  should 

*  It  will  be  perceived  that,  a  drachm  of  the  solution,  or  one  grain  of  the 
quinine  itself  is  intended  to  be  given  at  a  dose  by  this  formula;  as  a  tea-spoon 
is  supposed  to  hold  one  drachm.  In  the  Annali  Universal!  di  Medicina,  for 
November  and  December,  1828,  Dr.  Speranza  gives  an  account  of  a  successful 
mode  of  treating  tertian  fever,  by  the  endermic  method  of  applying  the  sul- 
phate of  quinine.  In  fifteen  cases,  the  fever  had  appeared  some  days  before 
he  prescribed  for  them.  With  the  exception  of  two,  there  was  no  very  mani- 
fest local  irritation;  and  in  these  the  symptoms  were  gastric.  Without  giving 
purgative  medicines  to  any  of  them,  he  had  a  blister  applied  immediately,  and 
in  most  of  the  instances  on  the  day  of  the  febrile  paroxysm;  the  sulphate  of 
quinia  was  put  on  at  the  end  of  the  fit,  or  the  beginning  of  the  apyrexia.  The 
arm  was  selected  for  the  application  of  the  blister,  as  the  most  convenient  for 
dressing.  Concentrated  vinegar  was  first  rubbed  strongly  on  the  part  to  hasten 
the  production  of  a  vesicle  by  the  blister.  After  removing  the  epidermis,  eight 
or  ten  grains  of  the  sulphate  mixed  with  a  small  portion  of  ointment,  was  placed 
upon  it.  The  wound  was  dressed  on  the  second  day,  and  every  thing  that  re- 
mained upon  its  surface  was  removed.  From  appearances,  one-half  of  the  sul- 
phate was  absorbed.  In  most  cases  the  fever  did  not  return  even  after  the  first 
application;  nor  was  it  necessary  to  repeat  it.  Not  only  primative  tertians  were 
treated  in  this  manner,  but  also  those  that  were  at  first  continued.  No  case  of 
relapse  was  known.  But  in  some  cases,  the  inflammation  of  the  arm  required 
topical  remedies. 


INTERMITTENT    FEVER.  93 

therefore  be  examined ;  and  if  it  be  found  still  active,  the  use  of 
the  bark  should  be  suspended  until  this  subside.  A  want  of  at- 
tention to  this  circumstance,  has  frequently  defeated  the  best 
powers  of  this  medicine.  But  when  the  system  is  in  a  proper 
condition  to  profit  by  its  exhibition,  we  should  give  a  drachm, 
every  hour  in  milk,  or  thin  molasses ;  or  a  grain  of  quinine,  un- 
til within  an  hour  of  the  time  of  the  expected  return  of  the  fit, 
if  it  be  a  quotidian ;  but  if  a  tertian,  or  quartan,  it  may  be  given 
every  two  hours — but  this  must  be  done  with  persevering  fide- 
lity during  the  day  and  night.  We  object  to  excessive  doses 
being  taken  immediately  before. the  returning  fit;  we  have  never 
seen  it  decidedly  useful  in  any  one  instance ;  and  we  believe  we 
have  seen  it  unequivocally  mischievous,  many  times. 

291.  There  is  a  great  variety  of  substances  purporting  to  be 
substitutes  for  the  bark;  but  as  far  as  our  experience,  or  infor- 
mation goes,  there  are  none  of  equal  value.     The  one  of  the 
vegetable  class  that  approaches  nearest  to  it,  in  our  estimation, 
is  the  cascarilla  bark,  (cortex  eleutheria,)  treated  pretty  much 
after  the  same  manner  as  the  bark  itself;  or  what  perhaps  is  a 
more  eligible  form  for  this  drug,  is  that  of  a  decoction.   In  some 
cases,  as  in  those  which  may  be  accompanied  by  cough,  or  puru- 
lent expectoration  from  the  lungs,  it  has  a  decided  advantage 
over  bark  in  any  form. 

292.  Neither  the  bark  nor  quinine  can  be  used  without  injury 
in  such  intermittents  as  are  accompanied  by  cough ;  (see  note  to 
par.  284)  or  any  congestion  of  the  lungs;  nor  has  it  ever  been 
useful,  when  this  disease  has  been  complicated  with  extensive 
visceral  obstructions. 

293.  Both  the  bark,  and  the  quinine,  run  off  by  stool  some- 
times, where  the  exhibition  of  either  would  otherwise  be  most 
proper;  to  prevent  this,  eight  or  ten  drops  of  laudanum  should 
be  occasionally  added  to  the  dose — or  the  patient  may  drink  now 
and  then  a  wine-glassful  of  tea  made  from  the  ground  allspice — 
this  to  be  useful  must  be  strong — at  other  times  the  bark  pro- 
duces obstinate  costiveness — to  obviate  this,  the  patient  should 
take  a  few  pills  made  of  rhubarb  and  soap,  or  aloes  and  soap,  at 
bed-time.  * 

*  The  following  pills  answer  this  purpose  admirably  well;  and  when  it  becomes 
necessary  to.persevere  in  any  laxative,  to  overcome  costiveness,  for  a  long  time, 
they  have  the  advantage  over  every  other  that  we  are  acquainted  with  :- 
R.  Gum.  aloes  sue.  -  3J. 


Pulv.  rhaei 
Ol.  caryoph.    -        -        gut.  vj. 
Sapo  venet.      -        -        gr.  viij. 
Syr.  rhaei          -         -         q.  s. 
M.  f.  pil.  Ix. 


Take  of  Socotorine  aloes     1  drachm. 
Powdered  rhubarb  2  drachms. 
Oil  of  cloves      -      6  drops. 
Castile  soap       -      8  grains. 
Syrup  of  rhubarb     sufficient. 
Make  60  pills. 


One,  two,  or  three,  of  these  may  be  taken  at  bed-time  when  necessary,  as  the 
constitutional  condition  of  the  bowels  may  require  either  a  small,  or  large  dose. 


94  INTERMITTENT    FEVER. 

294.  There  is  another  remedy  which  is  much,  and  justly  ex- 
tolled, for  the  cure  of  intermittents;  namely,  arsenic — as  far  as 
our  experience  enables  us  to  institute  a  comparison  between  it 
and  the  bark,  we  should  say,  it  is  fully  as  certain,  and  without 
some  of  its  inconveniences.     The  only  objection  that  we  believe 
can  be  urged  against  it,  is,  that  it  is  a  medicine  of  most  deadly 
power  when  improperly  used.     But  when  properly  exhibited, 
it  is  as  safe  as  opium,  or  any  other  medicine  in  daily  use.     We 
have  never  seen  the  least  injury  result  from  it — it  sometimes 
sickens  the  stomach,  and  occasionally,  even  to  vomiting — but  of 
what  medicine  of  any  power  may  not  the  same  be  said?* 

295.  The  arsenical  solution  has  a  decided  advantage  over  any 
preparation  of  bark,  when  children  are  the  subjects  for  its  exhi- 
bition— to  them  it  can  be  administered  with  the  fullest  effect, 
without  their  being  aware  they  have  taken  any  thing.   It  may  be 
given  when  the  system  cannot  receive  the  bark,  or  even  when 
the  pulse  is  too  full  to  bear  its  use.t     It  must  be  given  in  doses 
of  six  or  eight  drops  every  three,  four,  or  six  hours,  to  adults. 
Should  this  quantity  sicken  too  much,  or  be  rejected,  smaller 
doses  must  be  tried ;  and  this  will  very  rarely  fail  to  sit  well. 
To  children  from  one  to  two  years  old,  one  drop  or  a  drop  and 
a  half  may  be  given  every  four  or  six  hours — to  those  of  two  or 
six,  two  drops ;  from  six  to  twelve,  three  drops ;  and  from  twelve 
to  adult  age,  four  drops  may  be  used.     Should  it  prove  unplea- 
sant to  the  stomach,  let  it  be  given  with  a  drop  or  two  of  the 
essence  of  peppermint  and  water,  which  will  almost  always  cor- 
rect this  tendency  to  sickness.    The  only  obvious  effect  we  have 
witnessed  from  this  drug  beside  sickness,  is  a  swelling  of  the  eye- 
lids, especially  in  the  morning;  but  this  soon  goes  off,  if  the  me- 
dicine be  intermitted  for  two  or  three  days;  nor  is  it  of  any  con- 
sequence if  it  continue  a  short  time;  for  it  appears  only  as  an 
evidence  that,  the  medicine  has  had  a  constitutional  effect.    We 
have  never  known  it  but  once  to  affect  the  bowels,  and  then 
only  very  temporarily.     After  it  has  been  used  for  a  few  days, 
and  has  not  affected  the  stomach,  the  dose  if  necessary,  can  be 
increased  very  safely  two  or  three  drops  for  a  grown  person, 
and  proportionably  for  children. 

*  When  we  have  witnessed  the  most  decided  good  effects  from  this  medicine, 
it  has  alwas  been  in  recent,  or  at  least,  not  in  very  long-standing  cases — and  we 
think  it  more  successful  in  young,  than  in  old  subjects. 

•j-  The  arsenic,  like  every  other  tonic  or  stimulant,  employed  for  the  cure  of 
fever,  must  have  the  system  prepared  for  its  reception;  but  we  think  it  can  be 
given  earlier,  and  with  less  depletion,  than  the  bark.  Nor  is  it  a  matter  of  any 
consequence,  so  far  as  we  have  observed,  if  the  fever  be  not  absolutely  subdued 
at  the  time  of  its  commencement.  Indeed,  some  are  of  opinion,  that  this  me- 
dicine can  be  given  during  the  whole  march  of  the  disease.  As  regards  our 
own  experience,  we  confess  it  to  be  at  variance  with  this  declaration. 


INTERMITTENT    FEVER.  95 

296.  The  third  great  object  in  the  treatment  of  intermittents, 
is  to  prevent  a  relapse  after  the  fits  have  ceased  a  certain  time. 
There  is  no  disease  to  which  the  human  body  is  obnoxious,  that 
is  so  easily  provoked  to  return,  or  so  difficult  to  prevent  from, 
reappearing,  as  agues.     It  therefore  becomes  a  matter  of  great 
consideration  with  the  patient  to  know  how  he  shall  be  protect- 
ed against  its  renewal.    The  seventh,  ninth,  and  thirteenth  days, 
appear  to  be  the  most  frequent  periods  of  return;  but  agreeably 
to  our  own  observation,  the  thirteenth  is  the  most  common. 
Therefore,  to  prevent  this,  the  patient  should  be  particularly 
guarded  against  exposure,  on  the  days  designated  above — he 
should  two  days  before  each  of  these  periods  take  a  few  doses  of 
his  medicine;  either  the  bark,  quinine,  or  arsenic,  whichever  he 
may  have  employed — he  should  avoid  all  exposure  to  damp, 
cold,  or  heated  air — he  should  preserve  his  bowels  in  a  soluble 
state;   but  they  must  not  be  purged;   and  most  carefully  avoid 
fatigue  of  body,  or  emotions  of  mind.     But  above  all,  when 
practicable,  he  should  remove  from  the  place  where  it  originated, 
and  remain  from  it,  until  his  health  be  firmly  established. 

297.  As  this  disease  is  generally  supposed  to  arise  from  an 
excess  of  bile,  purgatives  are  too  often  employed  during  conva- 
lescence, with  a  view  to  its  removal;  than  which  a  greater  error 
can  hardly  be  committed.     We  are  certain  that  we  have  re- 
peatedly seen   relapses  produced   by   the   administration   of  a 
brisk  cathartic,  though  given  with  a  prophylactic  view.     We 
would   therefore  earnestly  caution  agaipst  this  plan  of  treat- 
ment. 

298.  We  have  admitted  it  to  be  every  way  proper,  to  keep 
the  bowels  soluble;  but  they  must  be  purged  with  great  caution, 
during  convalescence.     And  it  may  be  useful  further  to  suggest, 
that  much  care  is  required,  that  purging  shall  not  be  carried  too 
far,  even  when  there  may  be  a  renewal  of  the  paroxysms,  espe- 
cially if  the  interval  has  not  been  very  long,  or  if  the  returns 
have  been  previously  pretty  frequent.     Nor  is  it  a  matter  of  in- 
difference which  of  the  cathartics  we  employ.      Calomel    in 
divided  doses,  say  a  grain  every  hour,  until  five  or  six  grains  are 
taken,  is  the  best;  and  should  not  this  operate  in  two  hours  after 
the  last  portion  has  been  taken,  it  should  be  carried  through  the 
bowels  by  a  dose  of  castor  oil  or  magnesia.     But  even  this  cau- 
tious use  of  purgative  medicines  has  its  rules;  and  against  which 
it  would  not  be  safe  to  sin.     Calomel,  as  above  directed,  should 
be  given  only  during  the  appearance  of  unhealthy,  bilious  dis- 
charges; for  as  soon  as  the  feces  assume  their  natuarl  looks,  it 
should  be  desisted  from.  The  neutral  salts  are  always  improper, 
under  the  circumstances  just  stated. 


96  INTERMITTENT    FEVER. 

299.  Should  the  ague  be  of  long  standing,  and  the  stomach 
much  affected,  and  especially  with  people  advanced  in  life,  it 
becomes  very  important,  that  some  aromatic  should  be  joined 
with  the  remedies  just  recommended.     The  Virginia  snakeroot 
in  form  of  a  strong  tea,  where  sickness  attends,  is  of  great  value 
— but  where  the  stomach  is  merely  feeble,  and  flatulent,  cloves 
becomes  an  important  addition  to  the  bark.     Indeed,  in  many 
obstinate  cases  which  we  have  witnessed,  the  addition  of  cloves 
was  found  to  be  essential  to  the  cure.     We  have  oftentimes  suc- 
ceeded when  this  article  has  been  joined  to  the  bark,  in  form 
of  an  electuary,  when  every  other  we  had   employed,  even 
the   quinine,   had  proved   unavailing.     We  can   therefore  re- 
commend this  mode  of  exhibiting  the  bark,  with  great  con- 
fidence.* 

300.  Blisters  are  very  often  powerful  auxiliaries  in  the  cure 
of  intermittents — but  they  should  not  be  employed  too  early — 
the  pulse  should  have  lost  considerably  of  its  vigour,  before  they 
be  had  recourse  to.     In  protracted  cases,  and  especially  in  aged 
people,  they  may  be  used  with  great  advantage,  applied  to  the 
inner  side  of  the  calves  of  the  legs,  or  above  the  wrists,  on  the 
arms.     They  should  be  of  as  large  a  size  as  the  place  on  which 
they  are  to  be  applied  will  admit  of;  for  it  must  be  recollected, 
that  a  large  blister  gives  no  more  pain  while  drawing,  than  a 
small  one.  (See  par.  114.)     They  should  be  applied  at  a  period, 
that  will  secure  their  drawing,  at  about  the  time  the  fit  is  ex- 
pected. 

301.  Should  the  stomach  be  much  affected,  a  blister  can  be 
applied  over  its  region  with  much  advantage — this  should  be  in 
size  at  least  eight  inches  by  nine.     Should  the  head  particularly 
suffer,  the  blister  should  be  applied  between  the  shoulders,  and 
of  such  dimensions  as  will  pretty  nearly  occupy  the  space  of 
half  each  shoulder  blade,  both  in  depth  and  breadth,  up  to  the 
nape  of  the  neck. 

302.  In  our  account  of  fevers  in  general,  we  have  said  enough 
to  direct  the  diet  and  drinks  in  these  particular  fevers.      Should 
our  rules  on  this  subject  be  adhered  to,  we  believe  it  will  be  of 
advantage  to  the  patient,  although  we  differ  in  some  respects  on 

*  The  following  formula  is  the  one  we  are  in  the  habit  of  using: — 


Pulv.  C.  Peruv.  opt.  |ij. 

Pulv.  caryoph.        -  -        gj. 

Syr.  commun.          -  -        q.  s. 
M.  f.  elect. 


Take  Best  powdered  bark  2  ounces. 
Powdered  cloves  1  drachm. 
And  as  much  molasses  or  any 
other  syrup  as  will  make  it 


into  a  pretty  stiff  paste. 

Of  this,  the  size  of  a  nutmeg  must  be  taken  every  two  hours,  when  free  from 
fever. 


INTERMITTENT    FEVER.  97 

this  subject,  from  authors  of  great  experience  and  celebrity ;  and 
especially  the  European  writers.  We  find  in  most  of  them  a 
disposition  to  alter  the  diet  on  the  days  of  interval,  by  permitting 
an  indulgence  in  more  generous  food,  than  we  have  directed. 
This  may  be  right  in  their  climate,  and  in  the  diseases  of  them; 
but  in  this  country,  and  especially  in  the  middle  and  north- 
eastern states,  the  plan  we  have  laid  down  we  are  persuaded  is 
right;  and  we  must  insist  that  it  be  persevered  in,  until  the  pa- 
roxysms cease  to  return,  or  until  such  a  state  of  debility  super- 
venes as  will  call  for  this  change. 

303.  After  the  fits  have  been  interrupted  for  several  days,  the 
patient  may  be  permitted  to  eat  of  light  but  nourishing  food ;  and 
in  indulging  in  this,  he  should  be  cautious  not  to  go  too  far  at 
once.     He  may  now  be  permitted  to  eat  moderately  of  oysters, 
soft  boiled  eggs,  chicken  broth,  beef  tea,  or  thin  chocolate.  In  a 
few  days  more,  he  may  indulge  in  beef-steak  or  mutton  chop ; 
and  these  may  be  accompanied  by  a  tumbler  of  good  ale  and  wa- 
ter, or  porter  and  water — and  after  a  few  days  more  of  exemp- 
tion, he  may  return  to  his  usual  habits  of  eating,  except  upon 
the  days  pointed  out  for  his  guarding  against  a  relapse. 

304.  The  anxiety  to  arrest  the  returns  of  ague  is  sometimes 
so  strong,  as  to  lead  to  the  most  disastrous  means  of  effecting  it. 
Thus,  we  have  frequently  known  people  in  common  life,  (and 
occasionally,  indeed,  people  who  should  have  known  better,) 
take  for  this  purpose  large  quantities  of  ardent  spirits,  and  this 
sometimes  rendered  more  stimulating,  by  the  addition  of  pepper, 
just  before  the  expected  period  of  a  fit,  or  at  its  commencement, 
with  the  most  baneful  result.     We  once  knew  death  to  ensue 
very  shortly  after  this  vile  potation  had  been  swallowed  ;  and 
we  have  witnessed  a  number  of  instances  of  intermittents  being 
converted  into  continued  fevers  by  the  same  means.     But  can- 
dour obliges  us  to  confess,  we  have  also  known  it  to  succeed 
sometimes;  but  not  oftener,  nor  perhaps  so  often,  as  by  the  use 
of  the  remedies  we  have  proposed  for  this  end,  and  from  which 
no  mischief  can  result.  We  should  be  glad,  could  we  but  induce 
those  who  may  be  affected  with  this,  but  too  often  tedious  and 
obstinate  disease,  to  give  to  milder,  and  more  rational  means,  a 
fair  trial,  before  they  proceed  to  use  remedies  rarely  successful, 
very  often  decidedly  injurious,  and  sometimes  dangerous. 

305.  As  intermittents  for  the  most  part  have  marsh  miasma, 
for  their  remote  cause,  we  cannot  be  surprised  that  they  should 
be  protracted  to  almost  an  indefinite  period,  so  long  as  the  pa- 
tient continues  to  have  these  causes  operating  in  him.     Accord- 
ingly, many  are  doomed  to  be  victims  to  these  distressing  com- 
plaints for  many  consecutive  months,  notwithstanding  all  the 

13 


98  INTERMITTENT    FEVER. 

"appliances  and  means,  to  boot,"  have  been  industriously  em- 
ployed. It  therefore  becomes  in  many  instances  a  chronic  affec- 
tion, and  is  perpetuated  to  "immeasurable  length,"  by  the  force  of 
habit.  Patients  so  situated,  drag  on  a  miserable  existence,  until 
some  fortunate  application  breaks  the  spell,  and  restores  them  to 
tolerable  health. 

306.  It  is  a  desideratum  of  great  magnitude,  to  find  a  remedy 
which  shall  destroy  the  morbid  associations  which  give  rise  to 
these  repeated  and  long-protracted  paroxysms.     So  far  we  are 
not  in  possession  of  such  a  remedy,  although  we  have  several 
which  rarely  fail.  The  treatment  of  agues  in  the  southern  states, 
is  different  from  that  of  the  middle  and  eastern  states;  this  arises 
almost  exclusively  from  certain  localities,  and  the  influence  of 
climate.     In  the  southern  portions  of  our  union,  there  is  much 
more  extensive,  as  well  as  much  longer  application  of  the  causes 
which  produce  them ;  this  gives  to  the  disease  a  force  and  a 
fixedness,  that  is  rarely  known,  in  other  parts  of  the  United 
States. 

307.  From  constant  exposure  to  the  remote  causes,  the  pa- 
tient has  but  small  chance  of  a  speedy  cure;  accordingly,  he  is 
rarely  benefited  until  frost  has  destroyed  the  effluvia  that  gave 
rise  to  the  complaint.     By  the  time  spring  returns,  he  is  but 
barely  relieved  from  the  effects  of  his  summer  disease;  and  be- 
fore his  constitution  has  recovered  from  the  previous  shock,  he 
is  again  visited  by  his  ague.   Weakened  by  former  indispositions, 
the  noxious  causes  continue  to  operate  on  him  with  as  much  cer- 
tainty, if  not  with  equal  force,  as  before  ;  while  the  remedies, 
which  had  formerly  been  employed  with  success,  have  now  lost 
in  great  measure  their  power,  and  the  disease  can  no  longer  be 
held  in  check;  consequently  he  is  subject  to  it,  the  greater  part 
of  the  year — visceral  obstructions  form;  and  these  are  succeeded 
by  dropsy — he  crawls  a  living  spectre,  until  he  is  relieved  by 
the  kind  stroke  of  death. 

308.  This  is  but  too  frequently  the  melancholy  progress  and 
termination  of  intermittents  in  certain  districts  of  our  country;  to 
arrest  them  early,  and  permanently  to  keep  them  at  bay,  is  more 
to  be  coveted  than  expected;  at  least  so  long  as  the  patient  remain 
on  the  spot  from  whence  the  cause  proceeds.     To  remove  him 
then  is  a  matter  of  primary  importance  when  practicable ;  and 
where  not,  we  are  of  opinion  that  much  of  the  obstinacy  of  the 
disease  might  be  subdued,  if  proper  and  efficient  means  be  em- 
ployed in  the  commencement  of  the  attack.     By  efficient  means 
we  wish  to  be  understood,  the  proper  exhibition  of  cathartics; 
blood-letting;  and  occasionally  emetics  when  the  liver  is  goaded 
to  excessive  action,  &c. 


INTERMITTENT    FEVER.  99 

309.  By  the  constant  operation  of  the  remote  causes  in  such 
locations,  there  will  be  frequently,  an  unusual  secretion  of  bile ; 
and  although  we  are  by  no  means  of  the  opinion,  that  bile  is  the 
cause  of  intermittents,  yet  we  are  fully  persuaded,  nay,  certain, 
that  it  may  aggravate  the  disease  when  existing  in  excess,  in 
the  stomach  and  duodenum.     It  is  therefore  far  from  unusual 
that  the  patient  discharges  large  quantities  of  this  fluid  during 
the  whole  continuance  of  the  disease ;  which,  if  it  do  no  other 
injury,  will  very  frequently  prevent  the  employment  of  the 
bark,  and  other  medicine  given  with  the  view  to  interrupt  the 
paroxysms. 

310.  It  has  therefore  been  found  an  excellent  practice  in  such 
cases,  to  repeat  the  exhibition  of  emetics ;  and  occasionally  dur- 
ing the  paroxysm,  to  have  the  bowels  unloaded  by  mercurial 
cathartics.     In  the  southern  states,  where  they  are  much  expe- 
rienced in  this  disease,  emetics  are  much  resorted  to,  and  it  is 
said  with  decided  advantage;  but  we  fear  they  err  in  not  using 
laxatives  as  freely  as  they  should ;  and  almost  entirely  withhold- 
ing the  lancet,  even  where  there  is  unequivocal  evidence  of  a 
phlogistic  diathesis  present.   The  fear  of  inducing  weakness,  has 
led  to  this  reserved  use  of  the  lancet;  and  thus  a  contingent  de- 
bility, is  compounded  for,  by  the  certain  induction,  of  obstruct- 
ed abdominal  viscera. 

311.  The  bark  in  almost  all  its  forms,  as  a  remedy  in  inter- 
mittents, is  admitted  by  every  body  to  be  of  extraordinary  effi- 
cacy; but  it  is  equally  true,  that  it  requires  a  certain  condition 
of  the  system  to  ensure  its  success ;   and  that  condition,  is,  an 
entire  freedom  from  inflammatory  action.     Therefore,  when  this 
state  of  the  system  has  been  overlooked,  or  not  sufficiently  at- 
tended to,  we  find  intermittents  very  often  converted  into  re- 
mittents ;  or  the  force  of  the  disease  falls  upon  the  abdominal  vis- 
cera, to  the  ultimate  destruction  of  the  patient — hence,  as  we  have 
already  observed,  it  is  one  of  the  most  common  causes  of  ob- 
structed liver,  or  spleen,  or  both. 

312.  So  soon  then  as  there  is  a  determination  to  these  parts, 
we  cease  to  find  much  good  from  the  bark — the  practitioner  is 
surprised  at  his  want  of  success;  and  attributes  his  failures  to  the 
niggardly  doses  in  which  he  has  given  the  medicines ;  to  remedy 
which,  he  doubles,  nay,  sometimes  trebles  the  quantity,  with  no 
better,  or  perhaps,  with  even  worst  effect.  The  disease  now  be- 
comes habitual,  and  will  no  longer  yield  to  common  remedies — 
an  empirical  practice  is  now  adopted;  which  may  either  succeed, 
or  destroy,  as  chance  may  have  it. 

313.  One  of  the  most   deplorable   circumstances,  connected 
with  the  history  of  intermittents,  as  we  have  already  observed, 


100  INTERMITTENT    FEVER. 

is,  the  liability  of  the  paroxysms  to  return  after  they  have  been 
suspended  for  days,  weeks,  nay,  months ;  and  even,  when  the 
patient  has  been  removed  from  the  place  in  which  they  origi- 
nated. There  is  something  peculiar  in  the  nature  of  this  form 
of  fever;  since  it  creates  a  liability  to  return,  which  no  other 
form  of  fever  does.  A  remittent  passes  off  without  leaving  this 
disposition  behind  it,  provided,  it  has  not  terminated  in  the  in- 
termittent form:  when  this  happens,  there  is  certainly  a  risk, 
that  the  paroxysms  of  the  intermittent  may  be  repeated;  but  the 
danger  is  less  than  when  the  fever  presented  itself  originally  as 
an  intermittent. 

314.  To  protect  the  system  against  this  liability,  or  to  destroy 
the  disposition  to  it,  has  long  been  a  desideratum,  as  we  observ- 
ed  above;   and  many  substances  have  been  recommended,  and 
various  plans  proposed  for  this  purpose;  but  on  none  of  them,  so 
far  as  we  know,  can  implicit  reliance  be  placed.  The  plan  which 
has  often  succeeded  with  us  within  the  last  few  years,  is,  the 
persevering  use  of  the  black  pepper  corns.     Six  or  eight  are 
to  be  swallowed,  three  times  a  day,  about  fifteen  minutes  before 
each  meal,  and  continued  for  twenty  days ;  the  taking  of  them 
should  be  commenced  as  soon  as  the  febrile  paroxysms  have 
been  suspended. 

315.  We  have  lately  adopted  an  easier  method  of  exhibiting 
this  substance,  and  with  equal  success;  which  is  in  pills  made  of 
the piperine.*  A  grain  of  this  substance,  in  a  pill,  is  to  be  taken 
as  directed  for  the  pepper  corns.   It  can  now  be  procured  in  this 
city  without  difficulty.    The  dose  of  the  pepper  corns,  or  of  the 
piperine,  is  for  an  adult — so  far  we  have  only  witnessed  the  ef- 
ficacy of  this  remedy,  with  them;  we  are  yet  to  learn  its  powers 
with  children. 

316.  If  the  patient,  who  may  be  labouring  under  the  protract- 
ed form  of  ague,  can  be  removed  from  the  spot  on  which  the 
disease  originated,  he  may  speedily  recover,  by  the  use  of  the 
very  remedies,  which  before  his  removal  had  altogether  failed. 
But  if  a  change  of  place  be  impracticable,  we  are  obliged  to  com- 
bat the  complaint  in  the  best  manner  we  can,  though  it  be,  at 
fearful  odds. 

317.  Sometimes  by  new  combinations,  the  same  remedies  will 
prove  successful,  that  had  before  failed  even  in  large  doses;  thus 
bark  in  combination  with  certain  aromatics  will  stop  an  ague, 
(as  we  have  noticed  above,)  that  would  not  yield  to  any  quan- 
tity administered  alone.  The  prescriptions  in  the  margin,  beside 

*  The  piperine  is  the  proximate  principle  of  the  black  pepper;  and  bears 
the  same  relation  to  it,  as  the  quinine  does  to  the  bark. 


INTERMITTENT    FEVER, 


101 


the  one  just  mentioned,  are  of  this  kind  ;*  and  from  repeated  ex- 
perience of  their  efficacy,  we  can  safely,  and  confidently  recom- 
mend them.  My  friend,  Dr.  Chapman,  speaks  highly  of  the  blue 
vitriol,  (sulphate  of  copper,)  and  opium,  in  the  protracted  form 
of  this  complaint;  and  his  authority  for  its  usefulness  is  sufficient 
to  inspire  confidence.  His  formula  is  noticed  below.  It  is  also 
extolled  by  several  European  writers.t 

318.  When  visceral  obstructions  exist,  mercury  must  be  had 
recourse  to.  In  advising  this,  we  are  not  to  be  understood,  that 
it  should  be  exclusively  employed ;  we  mean  it  as  a  powerful 
auxiliary  to  the  tonics  which  must  now  be  substituted  for  the 
bark — such  as  Fowler's  solution;  sulphate  of  zinc;  sulphate  of 
copper;  the  decoction  of  cascarilla,  (cortex  eleutheria,)  &c.  for 
we  must  suspend  the  bark,  as  we  are  persuaded  it  is  an  improper 
remedy  under  such  circumstances.  The  best  modes  of  introduc- 
ing mercury,  is  either  by  friction,  or  by  the  blue  pill — two 
drachms  of  the  former  may  be  rubbed  in,  morning  and  evening, 
over  the  region  of  the  liver,  spleen,  or  the  inside  of  the  thighs, 
until  two  ounces  are  expended;  unless  a  lesser  quantity  have 
given  evidence  of  its  constitutional  action.  Should  the  mouth 
not  become  affected  after  a  lapse  of  four  or  five  days,  another 
ounce,  in  drachm  quantities,  may  be  rubbed,  as  before.  We  be- 
lieve these  quantities  will  be  every  way  sufficient  for  the  object 
for  which  they  are  prescribed;  that  is,  rather  as  an  alterative, 
than  as  a  syllagogue.  When  this  plan  is  inconvenient,  or  is  ob- 


*  R.  Pulv.  cort.  Peruv.  opt. 
Theriaca  androm.    - 
Pulv.  crem.  tart. 
Aq.  font.          -        .  " 
M. 


Take  Best  powdered  bark  6  drachms. 
Venice  treacle  -  3  drachms. 
Cremor  tartar  -  2  drachms. 
Water  6  ounces. 

Mix. 


Of  this,  when  practicable,  a  table-spoonful  is  to  be  taken  for  twelve  consecu- 
tive hours  before  the  chill  is  expected.     Or, 


Pulv.  cort.  Peruv.  opt. 
Rad.  serp.  virg.  - 

Gort.  aurant.      -        - 
Pulv.  caryoph.   -        - 
Carbon,  sodz     -        - 
M. 


. 
ss. 


Take  Best  powdered  bark  1  ounce. 
Virginia  snake-root     %  ounce. 
Orange  peel       -        2  drachms. 
Powdered  cloves        1  drachm. 
Potash  or  soda   -        1  drachm. 
Mix. 


This  powder  is  to  be  put  in  a  clean  earthen  vessel,  with  three  half  pints  of 
boiling  water — and  simmered  gently  until  it  is  reduced  to  a  pint — allow  it  to 
settle;  pour  off  from  the  sediment;  a  wine-glassful  every  hour,  for  eight  hours, 
before  the  chill  is  expected. 


•j-  R.     Sulph.  cupri.      -  gr.  ij. 

Gum.  opii  -        -  gr.  iv. 

Conserv.  rosar.    -  q.  a. 
M.  f.  pil.  xvj. 

One  every  morning,  noon,  and  evening. 


Take    Sulphate  of  copper    2  grains. 
Opium  4  grains. 

Conserve  of  roses,  enough  to 
make  into  sixteen  pills. 


102  INTERMITTENT    FEVER. 

jected  to,  the  blue  pill,  (pil.  hydragr.)  may  be  given,  in  three  or 
four  grain  doses,  morning  and  evening,  until  the  mouth  becomes 
slightly  affected.  Should  they  run  off  by  stool,  each  dose  must 
be  guarded,  by  a  quarter  or  half  a  grain  of  opium. 

319.  A  patient  subject  to  frequent  returns  of  this  fitful  dis- 
ease, should  be  careful  about  his  clothing,  especially  on  sudden 
changes  of  the  weather  from  hot  to  cold,  and  from  dry  to  wet. 
To  ward  off  the  ill  effects  of  these  transitions,  he  should  never 
be  without  flannel  next  his  skin,  and  this  should  frequently  be 
changed;  much  depends  upon  an  attention  to  this  point;  yet  no 
one  perhaps,  is  more  neglected.     It  is  too  commonly  believed, 
that  there  is  very  little,  if  any  necessity,  for  changing  of  the  flan- 
nel ;  and  it  is  worn  by  some,  for  months  together,  without  this 
being  done;  whereas,  it  should  be  renewed,  when  practicable, 
frequently,  (that  is,  at  least  twice  a  week,)  especially  by  those 
who  perspire  much. 

320.  Another  precaution  should  be  taken  by  invalids  of  this 
description,  (as  well  as  of  every  other  indeed,)  which  is,  never 
to  go  out  in  the  morning  without  having  taken  food  previously. 
We  may  with  propriety  in  this  place  suggest  another  caution; 
never  to  take  any  liquor  with  a  view  of  "fortifying  the  stomach." 
If  such  a  habit  has  been  indulged  in,  the  sooner  it  is  broken  the 
better;  and  this  may  be  done  both  successfully  and  advantage- 
ously, by  substituting  a  gill  of  strong  ginger,  or  calamus  tea,  for 
the  usual  spirituous  potation. 

321.  The  system  is  very  liable  to  lose  its  susceptibility  to 
medicine,  and  stimuli  of  every  kind  when  long  continued;  it  is 
therefore  of  consequence  not  to  persevere  too  long  with  any  one 
remedy,  and  this  is  especially  the  case  with  bark;*  therefore 
when  it  is  not  successful  in  arresting  the  paroxysms  by  a  fort- 
night's perseverance,  it  should  be  discontinued,  and  some  other 
remedy  tried;  or  else  alter  its  form,  which  sometimes  proves 
highly  efficacious. 

322.  But  we  should,  in  making  our  estimate  of  the  power  of 
the  bark,  be  certain  that  its  failure  is  owing  to  the  system  losing 
its  susceptibility  to  its  action;  or  we  may  confound  it  with  the 
phlogistic  condition  of  the  body — this  is  particularly  to  be  at- 
tended to  in  the  earlier  stages  of  the  disease,  and  especially  with 
such  patients  as  have  it  for  the  first  time. 

323.  In  dismissing  this  subject,  we  cannot  refrain  from  re- 
peating, how  truly  essential,  a  proper  and  effectual  preparation 
of  the  system  is,  for  the  best  effects  of  the  bark.     We  are  per- 

*  With  the  bark,  we  mean  to  include  the  quinine  and  Wetherill's  extract,  of 
course;  as  all  have  been  found  to  lose  their  powers  in  about  the  same  period. 
And  whenever  we  name  bark,  its  preparations  are  also  to  be  supposed  in- 
cluded, unless  otherways  expressed. 


INTERMITTENT    FEVER.  103 

suaded  this  has  not  been  attended  to  with  the  care  its  usefulness 
demands.  We  again  declare  it  to  be  our  opinion,  that  most  of 
the  failures  with  the  bark,  have  arisen  from  this  cause.  It  may 
not  however,  be  amiss  to  remark  that,  much  also  will  depend 
upon  the  quality  of  this  drug.  For  in  no  one  article  perhaps  of 
the  materia  medica,  are  we  so  likely  to  be  imposed  upon,  as 
with  this— it  is  either  weakened  by  improper  mixture,  or  a  kind 
is  substituted,  that  is  entirely  inert.  The  same  almost,  may 
now  be  said  of  the  quinine. 

324.  Within  the  last  few  years,  the  bark  in  substance,  has 
been  almost  altogether  superceded  by  the  quinine,  and  Wethe- 
rill's  extract,  which,  when  pure,  are  the  most  valuable  acquisi- 
tions, presented  to  us  by  modern  chemistry;  and  are  truly,  two 
of  the  most  certain  of  the  preparations,  of  this  extraordinary 
medicine.    We  have  already  glanced  at  some  of  their  advantages 
over  the  bark  in  substance,  and  we  shall  now  add,  that  their  ex- 
hibition is  more  generally  certain,  than  the  substance  from  which 
they  are  derived.     They  are  much  less  offensive  to  the  taste, 
though  intensely  bitter;  they  sit  better  upon  the  stomach;  and 
they  are  not  so  much  disposed  to  run  off  by  the  bowels.     Be- 
sides, their  bulk  may  be  reduced  to  almost  nothing;  the  grain 
pills  make  very  little  bulk;  and  the  quinine  in  solution  need  not 
exceed  a  tea-spoonful  at  a  dose. 

325.  Many  are  in  the  habit  of  exhibiting  the  quinine  into  pills; 
but  we  are  persuaded  from  repeated  experience,  that  it  often  fails 
when  given  in  this  form;   this  arises  perhaps  from  its  great  in- 
solubility; indeed  on  this  account,  much  care  is  required  to  pre- 
pare it  in  a  liquid  form.     The  best  formula  is  recorded  at  par. 
288. 

326.  The  quinine  is  a  costly  medicine  at  first  sight;  but  from 
all  the  estimates  we  can  make,  it  is  in  the  main  cheaper  than  the 
bark  itself.     Its  high  price,  and  the  great  demand  for  it,  has  un- 
fortunately led  to  its  adulteration.     The  genuine  quinine  is  a 
little  yellowish. 

327.  A  medicine  of  great  efficacy,  if  we  believe  Dr.  Jackson, 
(and  perhaps  no  one  is  better  entitled  to  credence,)  is  found  in 
the  cob-web;  which  he  assures  us  "is  more  effectual  in  prevent- 
ing the  return  of  febrile  paroxysms,  than  any  other  remedy,  of 
which  he  had  knowledge,"  he  further  adds,  "  I  think  I  may  ven- 
ture to  say,  that  it  prevents  the  recurrence  of  febrile  paroxysms 
more  abruptly,  and  more  effectually  than  the  bark  or  arsenic,  or 
any  other  remedy  employed  for  that  purpose  with  which  I  am 
acquainted;  that,  like  all  other  remedies  of  the  kind,  it  is  only 
effectual  as  applied  under  a  certain  condition  of  habit;  but  that 
the  condition  of  susceptibility  for  cob-web  is,  at  the  same  time, 
of  more  latitude  than  for  any  other  of  the  known  remedies.   The 


104  INTERMITTENT    FEVER. 

cob-web  was  rarely  given  until  the  subject  was  prepared  by 
bleeding,  emetic,  or  purgative,  and,  given  to  a  subject  so  pre- 
pared, has  seldom  failed  to  effect  a  cure  comparatively  permanent; 
relapse  or  conversion  into  another  form  of  disease,  being  upon 
the  whole  a  rare  occurrence,  where  the  disease  had  been  sus- 
pended by  this  remedy.  If  the  cob-web  was  given  in  the  time 
of  perfect  intermission,  the  return  of  the  paroxysm  was  pre- 
vented; if  given  under  the  first  symptoms  of  a  commencing  pa- 
roxysm, the  symptoms  were  suppressed,  and  the  course  of  pa- 
roxysm was  so  much  interrupted,  that  the  disease  for  the  most 
part,  lost  its  characteristic  symptoms.  If  it  was  not  given  until 
the  paroxysm  was  advanced  in  progress,  the  symptoms  of  irri- 
tation, viz.  tremors,  starlings,  spasms,  and  delirium — if  such 
existed  in  forms  of  febrile  action,  were  usually  reduced  in  vio- 
lence, sometimes  entirely  removed.  In  this  case  sleep — calm 
and  refreshing,  usually  followed  the  sudden  and  perfect  removal 
of  pain  and  irritation.  Vomiting,  spasms,  and  twisting  in  the 
bowels,  appearing  as  modes  of  febrile  irritation,  were  also  usually 
allayed  by  it;  there  was  no  effect  from  it  where  the  vomiting  or 
pain  were  connected  with  real  inflammation,  or  progress  to  dis- 
organization." 

328.  The  doctor  further  adds,  "the  cob-web  may  perhaps  be 
thought  to  belong  to  the  class  of  poisons;  but  it  is  somewhat  sin- 
gular that  I  have  never  been  able  to  discover  much  difference  of 
effect  from  a  dose  of  ten  grains  and  from  a  dose  of  twenty.    The 
changes  induced  on  the  existing  state  of  the  system,  as  the  effects 
of  its  operation,  characterize  a  powerful  stimulant.     1.  Where 
the  pulses  of  the  arteries  are  quick,  frequent,  irregular  and  irri- 
tated, they  become  calm,  regular  and  slow.     Almost  instanta- 
neously after  the  cob-web  has  passed  into  the  stomach,  the  effect 
is  moreover  accompanied,  for  the  most  part,  with  perspiration, 
and  a  perfect  relaxation  of  the  surface.     2.  Where  the  pulses  are 
slow,  regular,  and  nearly  natural,  they  usually  become  frequent, 
small,  irregular — sometimes  intermitting.     3.  Where  languor 
and  depression  characterize  the  disease,  sensations  of  warmth 
and  comfort  are  diffused  about  the  stomach,  and  increased  ani- 
mation is  conspicuous  in  the  appearance  of  the  eye  and  counte- 
nance."    Dr.  Jackson  then  specifies  the  particular  spider  from 
which  the  web  should  be  procured,  by  saying,  "the  cob-web 
here  recommended  is  a  product  of  the  black  spider,  which  inha- 
bits cellars,  barns,  and  stables;  that  which  is  found  upon  the 
hedges  in  autumn,  does  not  possess  the  same  power,  if  it  be  ac- 
tually of  the  same  nature." 

329.  The  high  encomiums  thus  bestowed  upon  this  curious 
substance,  should  tempt  us  to  fair  and  unprejudiced  trials  of  it — 
and  as  far  as  our  own  experience  goes,  it  is  much  in  favour  of 


INTERMITTENT    FEVER.  105 

this  medicine,  and  is  very  analogous  to  that  of  Dr.  Jackson's — 
we  however  confess,  that  our  experience  is  limited. 

330.  We  have  refrained  from  speaking  in  very  decided  terms 
of  the  practice  of  bleeding  in  the  cold  stage  of  "  intermittents," 
as  proposed  by  Dr.  Mackintosh,  (par.  231,  note.)  We  avoided 
this  subject  until  now,  that  we  might  collect  the  best  experience 
from  the  practice  of  others,  as  we  had  none  of  our  own  to  direct 
us.  We  have,  therefore,  come  to  the  conclusion,  that  sufficient 
has  been  ascertained  of  the  effects  of  this  practice,  to  make  us 
still  doubtful  of  its  usefulness.  We  have,  therefore,  selected 
the  conclusion  of  Dr.  Stokes'  candid  paper  upon  this  subject,* 
that  our  readers  may  judge  for  themselves  how  far  it  is  worthy 
of  imitation,  or  may  be  deserving  of  rejection.  Dr.  S.  relates  a 
number  of  cases  in  which  this  treatment  was  apparently  success- 
ful. He  appears,  however,  to  anticipate  objections  against  the 
plan;  which  gives  rise  to  the  following  remarks: — 

"  From  the  examination  of  these  cases,  I  apprehend  that  an  im- 
pression will  be  received  certainly  against  the  indiscriminate  or 
even  frequent  use  of  bleeding  in  the  cold  stage  of  ague.  It  may 
be  remarked,  that  in  the  great  majority,  quinine  had  to  be  ad- 
ministered before  the  disease  was  eradiated;  that  many  of  them 
had  an  extremely  slow  and  dangerous  convalescence;  that  in 
several  instances  the  disease,  so  far  from  being  relieved,  appeared 
exasperated  by  the  practice;  that  local  inflammatory  affections 
occurred  several  times  after  the  operation;  and  lastly,  that  the 
bleeding  appears  to  leave  a  tendency  to  convert  intermittent  into 
continued  fever.  In  one  case,  that  of  Casey,  death  from  pneu- 
monia and  softening  of  the  brain  occurred.  In  none  of  my  cases 
did  any  bad  effect  from  sinking  of  the  powers  of  life  follow  the 
practice  immediately.  But  I  am  informed,  that,  in  the  practice 
of  a  highly  respectable  individual,  there  occurred  two  cases  in 
which  the  patients  did  not  recover  from  the  collapse  produced 
by  bleeding  in  the  cold  stage.  These  facts  should  make  us  very 
careful  how  we  interfere  with  nature  by  means  of  the  lancet,  in 
simple  intermittent,  when  we  have  so  certain,  and,  as  far  as  I 
have  seen,  so  infallible  a  remedy  as  the  sulphate  of  quinine. 

"I  do  not  deny  that  cases  may  often  occur  where  venesection 
may  be  proper,  such  as  intermittent  complicated  with  severe  in- 
ternal inflammation;  but  shall  only  remark,  as  these  cases  have 
not  come  under  my  own  immediate  observation,  to  offer  my 
opinion  upon  a  purely  practical  point  connected  with  them 
would  be  wholly  useless.  I  shall  conclude  this  paper  by  insert- 
ing extracts  from  two  letters  which  I  have  received  on  the  sub- 

•  Edinburgh  Medical  and  Surgical  Journal,  for  January,  1829. 
14 


106  INTERMITTENT    FEVER. 

ject  of  bleeding  in  the  cold  stage  of  ague.  I  may  mention  that 
I  have  been  informed  by  my  friends,  Drs.  Townsend  and  Law 
of  this  city,  that  they  have  given  the  practice  a  trial,  and  have 
found  it  to  fail  in  the  majority  of  cases. 

The  first  letter  that  I  shall  quote  is  from  Dr.  Kelly  of  Castle- 
rea  in  the  west  of  Ireland. 

"  I  have  never  in  any  instance,  even  where  venesection  did 
not  prove  salutary,  known  fatal  disease  of  the  brain  to  follow; 
nor  have  I  ever  known  death  to  have  taken  place  in  three  hours 
after  the  opening  of  a  vein.  I  have  not  time  to  dwell  longer  on 
the  subject  now,  as  I  have  to  answer  your  queries. 

tf  Query  1st.   What  was  the  general  effect  on  the  cold  stage? 

"  tflnsw.  Isf.  That  of  cutting  short  the  rigor  and  rendering 
the  hot  stage  generally  milder. 

"  Query  2d.  What  was  the  effect  on  the  hot  and  sweating 
stage? 

"  Jlnsw.  2d.  I  have  never  tried  venesection  in  the  sweating 
stage,  and  but  once  in  the  hot,  when  I  thought  it  proved  inju- 
rious, by  inducing  great  prostration  of  strength. 

"  Query  3d.  What  was  the  effect  on  the  local  symptoms,  such 
as  cough,  pain,  &c.  &c.? 

"  Jlnsw.  3d.  It  decidedly  relieved  pain  of  the  head,  which  I 
have  oftentimes  known  to  be  intolerable  in  the  cold  stage.  It 
has  relieved  oppression,  pain  of  the  chest  and  side;  but  at  the 
time  of  bleeding  I  could  not  observe  any  change  as  to  cough;  and 
whenever  the  patient  laboured  under  cough,  immediately  after 
the  bleeding,  I  had  recourse  to  blisters;  therefore,  cannot  say 
which  of  the  remedies  was  most  useful  in  relieving  it. 

"  Query  4th.  What  was  the  effect  on  the  disease  generally  as 
to  preventing  the  return  of  the  paroxysm? 

"  Jlnsw.  4th.  It  had  generally  the  effect  of  rendering  the 
paroxysm  milder,  and  the  disease  more  manageable  by  other  re- 
medies. 

"  Query  5th.  Have  you  observed  new  local  inflammation  to 
follow  the  practice? 

"  Jlnsw.  5th.  I  have  observed  new  local  inflammation,  gene- 
rally pulmonic,  to  occur  after  bleeding;  but  I  never  did  imagine 
them  to  be  the  consequence  of  this  practice.  I  rather  attributed 
them  to  accidental  causes. 

"  Query  6th.  Have  you  treated  any  cases  by  blood-letting 
alone,  and  if  so,  with  what  result? 

"  Jinsw.  6th.  I  have  never  treated  any  cases  by  bleeding 
alone,  nor  do  I  think  it  safe  or  proper  to  do  so. 

"  Query  1th.  Have  you  observed  any  alteration  in  the  type 
of  the  fever  to  follow? 


INTERMITTENT    FEVER.  107 

"  Answ.  1th.  I  have  observed  alterations  frequently  to  occur 
in  the  type  after  this  practice;  but  this  I  have  observed  as  fre- 
quently in  cases  where  bleeding  was  not  tried,  when  we  trusted 
merely  to  other  remedies. 

"  Query  8th.  Has  disease  of  the  brain  followed  the  practice 
when  the  intermittent  fever  was  cut  short? 

"  Jlnsw.  8th.  I  never  knew  disease  of  the  brain  to  follow 
when  the  intermittent  had  been  cut  short. 

"  Query  9th.  Do  you  think  the  practice  most  applicable  in 
acute  or  in  chronic  cases? 

"  Jlnsw.  9th.  The  practice  is  more  generally  and  decidedly 
useful  in  acute  cases,  when  the  constitution  has  not  been  broken 
down.  At  the  same  time,  I  have  sometimes  seen  bleeding  useful 
in  chronic  cases  also. 

"  Query  10th.  What  is  the  quantity  of  blood  that  you  have 
generally  drawn? 

"  JLnsw.  10th.  I  never  exceeded  twelve  ounces  in  any  case, 
but  generally  did  not  take  more  than  from  six  to  eight.  I  never 
repeated  the  bleeding  a  second  time  in  the  same  case. 

"  Query  llth.  Has  the  disease  in  any  case  been  exasperated 
by  the  practice? 

"  »flnsw.  llth.  The  disease  has  appeared  to  me  in  some  cases 
to  have  been  exasperated  by  the  practice." 

The  following  is  an  extract  from  a  letter  for  which  I  am  in- 
debted to  my  friend  Mr.  Gill,  who  has  seen  much  intermittent 
in  the  fens  of  Lincolnshire. 

"  DEAR  SIR,  Nottingham  Park. 

*'  I  feel  very  sorry  that  your  letter  should  have  anticipated  my 
intention  of  writing  you,  as  perhaps  you  may  think  I  had  for- 
gotten my  promise  of  so  doing.  But  that  was  not  the  case.  I 
was  merely  waiting  to  give  you  more  fully  the  extent  of  my 
practice  in  intermittent  fever.  Without  any  more  preface  I  shall 
answer  your  queries  in  order.  1st,  '  How  often  have  you  em- 
ployed the  practice?'  Thirteen  times.  2d,  'What  have  you 
observed  as  to  its  effects  in  the  various  stages  of  the  paroxysm?' 
I  have  bled  five  times  before  the  usual  time  of  the  cold  stage  had 
arrived;  in  some  one  hour;  others  half  an  hour;  another  a  quarter 
of  an  hour;  and  in  one  two  hours  before  its  usual  time  of  appear- 
ance. The  result  was  as  follows: — In  the  first  case,  that  of  a 
strong  healthy  man,  the  cold  stage  occurred  daily  at  2  o'clock 
P.  M.  continuing  about  one  hcur,  and  followed  regularly  by  the 
hot  and  sweating  stages.  I  should  mention  he  had  never  before 
been  attacked  with  the  ague,  and  it  was  only  of  three  days  du- 
ration. I  bled  him  largely  plena  rivo,  one  hour  before  the  ex- 


108  INTERMITTENT    FEVER. 

pected  paroxysm,  viz.  at  1  P.  M.  At  ten  minutes  past  two,  how- 
ever, the  shaking  fit  came  on,  but  certainly  not  so  violent  in  de- 
gree as  the  previous  rigors.  He  complained  less  of  the  head- 
ache and  sickness;  and  at  a  quarter  to  three  this  stage  of  the  dis- 
ease had  disappeared,  being  fully  a  quarter  of  an  hour  of  less  du- 
ration than  previously;  but  I  am  sorry  to  add,  that  the  second 
stage  was  much  more  severe  and  protracted.  The  fever,  head- 
ache, and  restlessness  most  certainly  were  exaggerated,  and  an 
hour's  longer  continuance  than  before ;  and  this  hour  seemed  to 
me  as  if  taken  from  the  third  or  sweating  stage,  which  was  much 
more  moderate  than  usual;  but  the  patient  did  not  feel  that  re- 
lief which  he  had  done  before  in  this  stage  of  the  paroxysm.  I 
bled  this  man  the  next  day  at  the  same  hour,  and  took  away  an 
equal  quantity  of  blood.  The  cold  stage  came  on  in  the  same 
way  as  above  described,  and  continued  about  the  same  time,  but 
the  fever  was  again  more  violent  and  of  longer  duration,  and  the 
sweating  stage  in  the  same  proportion  less.  Notwithstanding 
these  unfavourable  symptoms,  however,  I  determined  the  next 
day  to  continue  the  practice;  but  on  my  visit  found  the  type  of 
the  fever  completely  altered;  in  fact,  the  man  had  all  the  usual 
symptoms  of  approaching  typhus,  viz.  violent  pain  in  the  head, 
black  fur  upon  the  tongue,  pulse  quick,  rather  feeble,  &c.  Of 
course  my  treatment  was  altered  ;  and  by  a  liberal  allowance  of 
stimulants  and  tonics,  with  saline  medicines,  this  man  fortunate- 
ly got  well.  I  have  given  you  fully  the  particulars  of  this  case, 
as  it  is  very  important  in  its  nature,  and  might  have  been  of  fatal 
termination. 

"  In  the  four  other  cases  where  I  bled  before  the  approach  of 
the  cold  stage,  I  must  candidly  say,  that,  if  I  saw  no  direct  ill 
arise,  most  certainly  I  saw  no  immediate  good.  Time  alone  can 
tell  whether  future  ill  effects  may  be  averted  by  this  plan  of 
treatment.  Again,  I  have  bled  five  men  during  the  shaking  fit. 
I  have  observed  in  four  of  these  that  the  fit  was  certainly  cut 
shortt  in  the  other  no  perceptible  alteration  was  visible.  Bleed- 
ing appears  to  me  certainly  to  have  the  power  of  cutting  short 
the  cold  stage,  but  then  by  so  doing,  it  seemed  to  be  the  means 
of  lengthening  the  febrile  stage,  and  in  almost  all  cases  I  found 
the  sweating  stage  diminished  in  a  ratio  with  the  length  of  the 
febrile  state.  Besides,  in  all  these  five  cases  the  fit  made  its  ap- 
pearance at  the  usual  time.  Some  of  these  patients  I  have  bled 
once,  others  twice'during  the  continuance  of  the  cold  fit;  and  I 
feel  morally  certain,  that  if  I  had  again  and  again  bled  them, 
typhoid  symptoms  would  have  been  induced.  If  you  wish  fur- 
ther and  more  minute  particulars  of  these  cases,  I  shall  be  most 
happy  to  furnish  you  with  them. 

"  I  have  practised  venesection  three  times  during  the  febrile 


INTERMITTENT    FEVEH.  109 

state,  where  the  pain  in  the  head  has  been  intense,  I  think  with 
good  effect  Perhaps,  then,  you  will  ask,  what  is  my  practical 
opinion  of  bleeding  in  the  cold  stage  of  ague?  My  opinion  must 
certainty  be  qualified.  In  the  fens  of  Lincolnshire  all  fevers 
partake  more  or  less  of  the  intermittent  character;  and  expe- 
rience teaches  us,  that,  by  what  cause  soever  debility  is  induced, 
continued  fever  will  be  the  effect  Whether  this  arises  from  any 
peculiar  state  of  the  atmosphere,  or  whether  it  is  a  natural  con- 
sequence, I  know  not,  though  I  am  inclined  to  think  the  former. 
From  this  fact  alone,  if  it  can  be  proved  that  venesection  during 
the  cold  stage  produces  debility,  the  practice  must  be  exploded; 
besides,  the  present  practice  here  is  successful  in  ninety-five 
cases  out  of  a  hundred.  By  successful  I  mean  not  only  in  curing 
the  present  symptoms,  but  in  preventing  future  ill  effects,  such 
as  enlargements  of  the  spleen,  liver,  pectoral  complaints,  &c. 
Our  practice  is  the  following: — 

"  On  the  first  appearance  of  aguish  symptoms,  an  emetic  is 
exhibited,  and  the  bowels  are  opened.  We  give  the  saline  mix- 
ture in  the  febrile  stage;  and,  as  soon  as  the  sweating  stage  is 
terminating,  we  administer  every  two  hours  two  grains  of  the 
sulphate  of  quinine,  with  a  liberal  allowance  of  port  wine.  In 
the  place  of  these,  after  the  symptoms  of  intermittent  have 
vanished,  the  patient  is  placed  under  an  alterative  plan  of  treat- 
ment, viz.  pills  of  submuriate  of  mercury  and  bitters,  which 
mode  of  treatment  we  find  almost  effectually  to  prevent  organic 
diseases. 

"  Your  third  query,  viz.  '  Has  it  in  many  cases  cut  short  the 
rigor?'  I  have  already  answered.  Your  4th  is,  *  Have  you  ob- 
served new  local  inflammation  to  follow  the  practice  ?'  Most 
certainly  I  have  not.  5th,  '  What  has  been  its  effects  upon  the 
local  symptoms  usually  present?'  I  have  generally  found  all  pa- 
tients during  the  shaking  stage  suffering  from  cough  and  difficulty 
of  breathing.  Bleeding  undoubtedly  relieves  these  symptoms 
as  well  as  the  pains  experienced  in  the  splenic  and  hepatic  re- 
gions; but  when  we  consider  the  stethoscopic  examination  dis- 
covers no  bronchial  inflammation  immediately  after  the  cold 
stage  has  terminated,  bleeding  can  never  be  recommended  on 
that  account. 

"  To  the  question,  whether  the  type  of  the  fever  was  altered? 
I  have  already  adverted  sufficiently.  6ih,  '  As  to  whether  dis- 
eases of  the  brain  followed?7  I  cannot  give  you  any  information 
from  experience  on  that  point  Upon  the  whole,  from  an  im- 
partial review  of  all  the  cases  in  which  I  have  practised  bleeding 
in  the  cold  stage  of  ague,  I  should  most  certainly,  as  a  moral 
practitioner,  give  my  decided  veto  to  the  practice,  conceiving 
it  not  only  to  be  useless,  but  dangerous  when  indiscriminately 


110  REMITTENT    FEVER. 

followed, — I  say  indiscriminately,  for  cases  might  occur  where 
I  should  think  venesection  might  be  necessary, — such  as  when 
a  person  suffering  from  pulmonary  inflammation  is  attacked  with 
aguish  symptoms,  &c. 

"  It  is  an  anomaly  which  I  cannot  explain,  that  in  Lincolnshire, 
where  the  atmosphere  is  perpetually  moist,  and  where  the  mists 
and  exhalations  are  excessive,  cases  of  pulmonary  consumption 
are  very  rare  indeed.  Would  you  not  suppose  that  in  persons 
predisposed  to  phthisis,  these  pulmonary  congestions  would  act 
as  an  exciting  cause?"* 

SECT.  II. — REMITTENT  FEVER. 

331.  When  a  fever  consists  of  repeated  paroxysms,  (that  is, 
regular  exacerbations  and  declines,)  but  without  a  distinct  inter- 
mission between  the  paroxysms,  it  is  called  a  remittent  fever. 
In  these  cases,  it  is  observed  that,  though  the  hot  and  sweating 
stages!  do  not  entirely  cease  before  the  twenty-four  hours  have 
expired  from  the  beginning  of  the  paroxysm,  the  fever  is  found 
to  have  suffered  considerable  abatement,  or  a  remission  of  their 
violence;  but  at  the  return  of  the  quotidian  period,  the  paroxysm 
is  again  renewed,  and  runs  the  same  course  as  before.     This 
form  has  therefore  no  absolute  apyrexia,  nor  is  it  necessarily 
preceded  in  its  onset  by  chill ;  nor  the  succeeding  exacerbations 
anticipated  by  a  sense  of  cold. 

332.  This  fever  commences  very  much  like  an  intermittent; 
it  is  preceded  by  languor  and  anxiety,  listlessness,  yawning, 
and  sometimes  by  alternate  fits  of  heat  and  cold;  pain  in  the  head 
or  back,  of  greater  or  less  intensity ;  the  heat  over  the  whole  body 
is  much  augmented ;f  thirst;  more  or  less  difficulty  of  breathing; 

*  "  On  the  curious  fact  that  in  marshy  districts,  in  which  ague  is  frequent, 
pulmonary  consumption  is  little  known,  Dr.  Wells  many  years  ago  collected 
a  great  deal  of  evidence.  But  of  these  facts  no  general  principle  entitled  to 
the  character  of  an  explanation  has  yet  been  discovered. — Transactions  of  a 
Society,  &.c.  vol.  iii." 

f  A  sweating  stage  does  not  always  belong  to  this  form  of  fever — we  have 
seen  many  instances  to  the  contrary  of  this;  and  never  more  frequently,  per- 
haps, than  in  the  fevers  of  the  fall  of  1828,  when  they  assumed  the  remittent 
form.  In  almost  all  these  cases,  there  were  two  exacerbations  in  twenty-four 
hours,  at  about  twelve  hours  interval.  The  first,  at  seven  or  eight  o'clock  in 
the  morning,  and  the  other  about  the  same  hour  in  the  evening.  These  con- 
ditions would  continue  for  three  or  four  days,  before  any  marked  solution  of 
the  fever  would  take  place,  by  sweating.  A  partial  moisture  was  sometimes, 
however,  observed,  upon  the  decline  of  the  heat  of  the  body. 

$  This  is  not  universally  the  case;  this  form  of  fever  has  its  characters  to 
vary  like  all  others,  and  by  causes  altogether  inscrutable;  and  especially  when 
it  becomes  epidemic.  In  many  instances  of  this  fever  in  the  fall  of  1828,  the 
extremities  would  remain  cold;  especially  the  lower,  for  many  hours  together; 
while  the  other  parts  of  the  body,  and  the  head  particularly,  would  be  exces- 


REMITTENT    FEVER.  Ill 

tongue  for  the  most  part  white ;  spirits  dejected ;  and  frequently, 
the  skin  and  eyes  have  a  tinge  of  yellow ;  sometimes  nausea,  and 
vomiting  of  bilious  matter ;  pulse  frequent,  full  or  small,  tense 
or  soft,  as  the  constitution  may  be  affected  by  the  remote  causes. 
After  these  symptoms  have  continued  for  some  time,  the  fever 
is  found  to  abate  considerably  ;  or  there  is  an  attempt  at  perfect 
solution  by  partial  sweats  breaking  out,  but  it  is  rarely  completed; 
for  after  a  lapse  of  a  few  hours,  the  same  routine  of  symptoms 
are  again  observed.  After  a  continuance  for  some  time  of  alter- 
nate remissions  and  exacerbations,  a  crisis  takes  place ;  or  if  the 
disease  has  been  neglected,  or  improperly  treated,  it  may  be  con- 
verted into  a  fever  of  the  continued  type. 

333.  There  is  no  inconsiderable  difference  in  the  grades  of 
this  fever,  as  constitution,  seasons  of  the  year,  and  climate,  may 
modify  the  force  of  the  remote  causes,  &c.    In  the  milder  forms 
of  this  disease,  delirium  for  the  most  part  is  absent ;  but  in  the 
more  exalted,  it  comes  on  with  the  first  symptoms,  and  per- 
tinaciously continues  through  the  whole  course  of  the  complaint. 
When  this  obtains,  we  may  remark  an  aggravation  of  all  the 
other  symptoms;  but  these,  like  the  former,  suffer  a  small  abate- 
ment at  the  period  of  remission ;  but  for  the  most  part,  the  pa- 
tient profits  very  little  by  this  partial  truce,  as  the  succeeding 
exacerbations  are  attended  by  aggravated  symptoms,  and  some- 
times even  death  ensues.     When  about  to  terminate  favourably, 
the  contrary  to  what  has  just  been  mentioned  takes  place;  the 
remission  is  of  longer  continuance ;  and  the  state  of  the  disease 
during  this  reduction  is  milder;  the  exacerbation  which  follows 
is  of  less  intensity  than  the  former;  the  sweat,  before  partial,  now 
becomes  general;  the  delirium  less  ferocious;  the  pulse  softer 
and  more  tranquil;  the  breathing  less  oppressive;  and  eventually 
a  crisis  takes  place  on  the  tenth  or  twelfth  day,  or  in  hot  cli- 
mates, on  the  fifth,  perhaps. 

334.  We  should  never  persuade  ourselves,  that  this  disease 
is  not,  or  may  not  be  dangerous  ;  for  it  sometimes  has  a  fatal  ter- 
mination, even  under  the  best  treatment.     This,  however,  more 
certainly  happens,  when  the  remedies  have  been  either  injudi- 
ciously, or  feebly  administered  ;  or  where  they  have  not  been 
applied,  until  the  patient  was  already  in  jeopardy.     As  a  gene- 
ral rule,  we  may  say  of  it,  that,  in  proportion  to  the  distinctness 
of  the  remission ;  or,  in  other  words,  the  nearer  it  approaches  to 
the  intermittent  form,  will  be  the  exemption  from  danger ;  while 

sively  hot.  Indeed,  the  feet  and  legs  were  difficult  to  warm,  even  by  the  re- 
peated application  of  hot  things;  as  heated  bricks,  or  bottles  of  hot  water. 
When  this  disposition  to  become  cold  prevails,  we  should  never  fail  to  attempt 
its  removal,  by  the  means  just  named.  In  some  cases  we  were  obliged  to  have 
recourse  to  hot  brandy  and  Cayenne  pepper  for  this  purpose. 


112  REMITTENT    FEVER. 

on  the  other  hand,  the  shorter  and  more  obscure  the  remission, 
the  greater  will  be  the  danger. 

335.  Dissections  prove  that,  (at  least  in  almost  all  the  fatal 
cases  which  have  been  noticed,)  there  are  strong  local  determi- 
nations of  blood  especially  to  the  stomach,  head,  and  liver;  and 
that  very  often  there  is  an  inflammation  of  these  parts.     In  this 
country  this  obtains  with  almost  as  much  certainty,  as  within  the 
tropics;*  and  the  disease  very  frequently  runs  its  course  with  the 
same  appalling  rapidity.     We  should  therefore  attend  to  this  dis- 
ease with  a  watchful  eye,  and  rejoice,  when  it  does  not  elude 
our  vigilance.  The  treatment  of  it  must  be  both  prompt,  and  de- 
cisive; half-way  measures  will  rarely  succeed,  unless  it  be  in  its 
very  mildest  form. 

336.  The  treatment  of  this  disease  differs  very  much  from 
that  of  an  intermittent.  We  rarely  dare  commence  with  an  eme- 
tic ;  indeed  only,  when  this  complaint  assumes  its  very  mildest 
appearance;  and  when  the  stomach  is  evidently  irritated  by 
bile.t     We  mention  this,  and  we  wish  to  be  understood  as  lay- 
ing some  stress  upon  it,  because  it  is  a  prevailing  error,  that 
"  all  fevers  are  accompanied  by  a  copious  secretion  of  bile;  there- 
fore, the  attempts  at  cure  should  be  premised  by  an  emetic." 
We  are  persuaded  that  in  several  instances  within  our  own  ob- 
servation, an  emetic  had  a  decidedly  mischievous,  if  not  a  fatal 
tendency.     From  the  force  of  arterial  action,  arising  from  the 
phlogosed  state  of  the  stomach,  and  the  constant  tendency  to  lo- 
cal determinations,  bleedingj  must  be  had  recourse  to  as  early  as 
possible;  and  the  quantity  to  be  drawn  must  be  regulated^by  the 


*  We  have  already  acknowledged  our  obligations  to  the  French  patholo- 
gists,  for  the  extent,  and  precision  of  their  remarks  upon  the  dead  fever  sub- 
jects— indeed,  they  seem  to  have  done  almost  every  thing  which  is  required 
upon  this  point;  and  the  truth  of  their  observations,  as  regard  the  condition  of 
the  stomach;  as  well  as  the  practical  conclusions  deduced  from  them,  are  now 
almost  as  universally,  as  profitably,  admitted.     Yet  it  is  due  to  Dr.  Physick 
to  say,  that  he  made  like  discoveries  as  early  as  1793,  when  the  yellow  fever, 
was  epidemic  in  this  city.     And  we  may  add,  with  a  view  to  show  how  slowly 
new  truths  are  received,  especially  when  such  truths  are  calculated  to  destroy 
old  prejudices,  that  his  skill  as  a  physician,  as  well  as  that  of  an  anatomist, 
were  called  in  question,  the  instant  he  published  his  discoveries  to  the  world. 

f  It  now  and  then  happens,  that  a  fever  of  a  remittent  form,  is,  in  its  onset, 
accompanied  by  a  vomiting  of  a  bilious  matter.  The  stomach  in  this  case  is 
extremely  irritable,  and  refuses  to  retain  any  thing  offered  it — neither  food 
nor  medicine,  will  lie  upon  it  an  instant  when  this  happens;  occasionally,  ad- 
vantage is  found  from  emptying  this  viscus,  by  the  exhibition  of  ipecacuanha. 
"We  rarely  venture  upon  the  antimonial  preparations;  as  we  are  of  opinion, 
that  much  mischief  has  followed  their  operation.  This  is,  perhaps,  not  of  diffi- 
cult explanation,  if  the  pathology  we  have  adopted  of  this  disease,  be  correct. 

*  We  would  wish  to  be  understood  here,  to  mean  local  bleeding,  if  neces- 
sary, as  well  as  general.  The  general  bleeding,  as  a  common  rule,  should  first 
be  had  recourse  to. 


REMITTENT    FEVER.  113 

intensity  of  the  symptoms.  The  regulations  we  have  already 
laid  down  for  this  remedy  must  be  strictly  complied  with;  espe- 
cially the  one  which  refers  to  the  change  which  must  be  induced 
on  the  pulse.  Without  changing  the  force  or  naturo  of  the  ac- 
tion of  the  circulatory  system,  we  do  little,  perhaps  nothing,  nay, 
sometimes  mischief.  Therefore,  where  pain  in  the  back  and  head 
are  severe,  we  should  not  stop  the  flow  of  blood,  until  they  are 
relieved,  or  much  mitigated  ;  and  this  rarely  ever  will  be  the  case, 
before  the  pulse  is  reduced  in  a  very  evident  manner.  We  are  to 
decide  upon  the  quantity  to  be  drawn,  entirely  by  the  effects  it 
produces  upon  the  pulse;  and  not  by  either  weight  or  measure. 
In  some  cases  a  very  few  ounces  will  afford  instant  relief,  while 
others  may  require  the  loss  of  many.  We  have  frequently  seen 
a  large  bleeding,  immediately  followed  by  a  profuse  perspira- 
tion, much  to  the  relief  of  the  patient,  and  we  were  persuaded, 
at  the  moment,  that  a  small  one  would  not  have  produced  such 
an  effect. 

337.  We  have  several  times  declared,  that  dissections  have 
proved  that  the  stomach  is  in  a  state  of  greater  or  less  inflamma- 
tion, in  the  greater  part  of  fevers ;  and  this  is  so  readily  de- 
tected in  most  instances  by  pressure  made  over  its  region,  that 
we  may  almost  constantly  satisfy  ourselves  of  the  fact.  In  making 
this  examination,  and  it  should  never  be  omitted,  we  must  take 
care  not  to  apply  a  force,  that  would  of  itself  create  pain,  inde- 
pendently of  the  diseased  condition  of  the  stomach,  just  spoken 
of.     The  part  most  sensitive  in  general,  is  the  hollow  space  at 
the  lower  extremity  of  the  sternum,  or  breast  bone.     If  two  or 
three  fingers  be  made  to  press  gently  and  gradually  upon  this 
part,  and  the  patient  evince  or  acknowledge  that  he  experiences 
pain  from  the  trial,  we  are  assured  almost  beyond  a  doubt,  that 
the  stomach  is  labouring  under  a  greater  or  lesser  degree  of  in- 
flammation.    Hence  the  propriety  and  oftentimes  the  absolute 
necessity,  of  having  recourse  to  topical  bleeding,  either  by  the 
means  of  leeches  or  cups ;  especially  after  a  bleeding,  or  bleed- 
ings from  the  arm,  have  been  performed.     In  a  number  of  in- 
stances, we  have  seen  a  complete  intermission  instantly  procur- 
ed by  the  loss  of  five  or  six  ounces  of  blood  by  leeches  from  the 
region  of  the  stomach.     Nor  do  we  always  require  the  presence 
of  tenderness  from  pressure,  to  induce  us  to  have  recourse  to 
leeches.     On  the  contrary,  we  have  known  this  to  be  absent; 
yet  the  most  decided  benefit  to  follow  their  use.     Therefore 
whenever  the  fever  is  obstinate,  they  should  be  employed  with- 
out further  loss  of  time. 

338.  After  having  bled  the  patient,  we  should  attend  to  the  state 
of  the  bowels — they  should  be  promptly  and  freely  evacuated; 
for  this  purpose,  a  small  dose  of  calomel,  say  six  grains,  should 

15 


114  REMITTENT    FEVER. 

be  given,  and  this  followed  in  two  hours  hy  an  ounce  of  castor 
oil;  which  must  be  repeated,  if  it  does  not  act  sufficiently  in  two 
or  three  hours.  We  rarely  repeat  the  calomel  the  same  day.  Or 
we  may  use  with  much  advantage,  the  Epsom  salts  and  calcined 
magnesia;  or  castor  oil  alone.  The  salts  and  magnesia  are  given 
in  the  following  proportions. 


R.   Sulph.  magnes. 

Magnes.  alb.  ust.,  aa. 
M.  et  div.  in  iij. 


Take  Epsom  salts, 

Calcined  magnesia, 

each,  3  drachms. 


Mix  and  divide  in  3  parts. 

One  to  be  taken  every  hour,  mixed  in  sweetened  water  or  le- 
monade, until  they  operate  freely. 

339.  The  castor  oil  should  be  given  in  ounce  doses,  every  two 
or  three  hours  until  it  operate.     It  is  always  best  to  make  the 
oil  very  thin,  by  warming  it. 

340.  Generally  it  is  best  to  give  these  medicines  in  divided 
doses,  and  repeat  them  until  a  full  effect  be  produced — the  inter- 
vals at  which  they  shall  be  given  are  indicated  by  the  prescrip- 
tion.    If  a  copious  perspiration  ensue,  we  'may  be  assured  we 
have  lessened  the  force  of  the  exacerbation;  and  that  the  succeed- 
ing one  will  be  milder;  but  we  must  not  be  lulled  into  the  belief 
that  it  will  require  no  further  care — on  the  contrary,  it  should  be 
watched  with  attention,  and  made  to  undergo  a  discipline  pre- 
cisely similar  to  the  one  just  mentioned  ;  provided,  the  force  of 
the  pulse,  head-ache,  &c.  make  it  proper  to  lose  more  blood — 
the  quantity  now  to  be  drawn  may  be  less;  but  the  lancet  must 
not  be  withheld,  if  pain  attend,  and  the  pulse  be  still  active.   The 
bowels  must  again  be  opened  by  the  same  means  as  before;  but 
not  to  the  same  extent,  unless  the  evacuations  are  decidedly  bi- 
lious, very  dark-coloured,  and  offensive.     Should  perspiration 
ensue,  and  terminate  the  paroxysm,  we  may  perhaps,  gain  a 
complete  intermission,  and  the  disease  change  its  type  to  that  of 
intermittent;  in  this  event,  it  must  be  treated  as  already  di- 
rected for  that  fever. 

341.  It  is  not  a  matter  of  indifference,  at  what  part  of  the  pa- 
roxysm we  abstract  blood,  either  from  the  arm,  or  from  the  skin 
over  the  stomach  by  leeches,  or  cups.     We  are  of  opinion,  and 
think  we  are  not  mistaken  when  we  say,  mischief  has  followed 
the  loss  of  blood,  when  it  has  been  abstracted  near  the  end  of 
the  paroxysm;  especially,  when  the  habit  of  the  fever  is,  to  ter- 
minate by  sweat.     We  are  therefore  constantly   careful  to  di- 
rect this  operation  some  time  before  the  exacerbation  is  about  to 
decline. 

342.  If  the  paroxysm  does  not  terminate  by  perspiration  ;  and 
the  patient  continue  restless,  hot,  and  thirsty,  with  very  little  or 
no  abatement  of  fever,  we  may  be  pretty  certain  that  the  re- 


REMITTENT    FEVER.  115 

medics  have  not  diminished  the  force  of  the  disease ;  and  espe- 
cially, if  delirium  should  now  attend,  or  become  augmented.  In 
this  case,  we  must  disregard  what  has  already  been  done  for  the 
patient;  and  industriously  apply  ourselves  to  ward  off  the  threaten- 
ing mischief — with  a  view  to  this,  we  must  carefully  consult  the 
pulse,  and  the  attending  symptoms,  as  to  the  propriety  of  the 
further  abstraction  of  blood — should  the  pulse  be  still  active,  the 
head-ache  severe,  or  other  pain  continue,  we  should  again  tie  up 
the  arm,  and  allow  more  blood  to  escape — the  quantity  must  be 
regulated  by  existing  circumstances,  that  is,  by  the  reduction  of 
the  pulse,  or  by  the  alleviation  of  symptoms.     Should  the  pulse 
not  be  so  active,  (which  by  the  by,  will  rarely  happen  at  this 
period  of  this  disease,)  as  to  justify  further  depletion  from  the 
arm ;  if  head-ache,  and  other  evidences  of  local  determination 
exist,  or  the  tenderness  in  the  epigastric  region  be  undiminished, 
or  augmented,  we  may  take  away  blood  by  leeching,  or  cupping, 
and  may  again  deplete  from  the  bowels.     In  this  state  of  things, 
the  latter  object  is  admirably  obtained  very  often  by  the  use  of 
the  nitro-antimonial  powders.*  Or  should  the  disease  suffer  some 
mitigation,  that  is,  the  abatement  of  the  symptoms  just  enume- 
rated, we  may  employ  the  same  powders,  with  great  advantage, 
or  simply  the  neutral  mixture.!     It  may  be  well  to  remark  here 
that,  in  remittents  of  very  active  stages,  the  utmost  advantage  is 
derived  from  carefully  watching  the  exacerbations,  and  by  never 
suffering  a  paroxysm  to  pass  without  the  abstraction  of  blood  so 

*  The  following  is  the  formula  for  these  powders. 


R.  Nitrate  of  potass,       -  -      JJtss. 

Tartrite  of  antimony,  -    gr.  j. 

Calom.  ppt.  gr.  iv. 
M.  div.  in  viij. 


Take  nitre,  1J  drachm. 

Tartar  emetic,     -     1  grain. 
Galomel,  4  grains. 

Mix  and  divide  in  8  parts. 


One  of  these  to  be  given  every  two  hours  mixed  in  a  little  syrup  of  any  kind. 
The  number  to  be  given  must  be  determined  by  their  effects  up  on  the  bowels. 
If  they  purge  too  freely  they  must  be  suspended,  until  further  necessity. 

f  Formula  for  the  neutral  mixture. 


Mist  neutral, 

Aqua  font.  aa.         -        -      ^iij. 
Tart,  antim.  -        -      gr.  j. 

M.  f.  sol. 


Take  Carbonate  of  soda 

or  potass,         -  2  drachms. 

Lemon  juice,      -  3  ounces, 

Tartar  emetic,    -  1  grain. 


Water,  3  ounces. 

M.  and  dissolve,  a 

A  table  spoonful  to  be  given  every  hour  or  two,  during  the  active  state  of 
the  fever. 

a  When  making  this  mixture,  care  should  be  taken  to  first  strain  the  lemon 
juice,  then  add  it  very  gradually  to  the  soda  or  potass  until  the  effervescence 
ceases.  Let  the  tartar  emetic  be  dissolved  in  the  water  before  it  is  mixed  with 
the  neutral  mixture.  Sugar  may  be  added  to  the  taste,  if  required. 


116  REMITTENT    FEVER. 

long  as  the  pulse  is  active,  the  face  much  flushed,  the  skin  very 
hot,  and  the  head-ache  severe.  Some  years  ago,  in  some  of  our 
autumnal  remittents,  so  mischievous  was  the  neglect  of  this  rule, 
that  with  a  number  of  practitioners  it  became  an  aphorism  that, 
"  to  lose  a  paroxysm  was  to  lose  a  patient." 

343.  As  our  remittents  are  very  much  influenced  by  causes 
which  we  neither  see  nor  have  controul  over,  we  shall  find  their 
force  very  different,  in  different  years.     In  our  directions  for 
their  treatment,  which  necessarily  must  be  general,  we  must  con- 
stantly be  understood  to  mean,  that  the  remedies    are    to    be 
adapted  to  the  force  with  which  the  disease  attacks ;  the  period 
to  which  they  run,  and  the  particular  character  they  may  assume. 
Thus  we  find,  in   some  years  they  are  mild,  tractable,  and  of 
considerable  duration;  in  others  they  are  fierce,  rapid,  and  quickly^ 
terminate  in  health  or  death.     The  remedies  must  therefore  be 
regulated  by  these  modifications. 

344.  If,  after  due  depletion,  we  find  a  disposition  to  crisis  by 
perspiration,  we  should  endeavour  to  encourage  it  by  such  mild 
diaphoretics  as  will  create  no  disturbance  in  the  system,  if  they 
fail  to  procure  sweat.     For  this  purpose  we  may  exhibit  small 
doses  of  tartar  emetic,  as  directed  above  in  the  neutral  mix- 
ture ;  warm  lemonade,  or  baum  tea,  with  forty  or  fifty  drops  of 
the  sweet  spirit  of  nitre;  or  apply  the  vapour  of  vinegar,  by 
means  of  heated  bricks,  saturated  with  this  substance.     Should 
the  external  application  fail  to  produce  perspiration  in  half  an 
hour,  it  should  be  desisted  from  ;  for  further  perseverance  will 
not  only  be  unavailing,  but  even  injurious.     This    indisposi- 
tion to  moisture  is  almost  always  owing  to  too  active  a  state  of 
the  pulse,  or  too  high  a  temperature  of  the  skin — if  the  first,  we 
must  deplete  more ;  if  the  latter,  we  must  reduce  the  excess  of 
heat  by  cool  drinks,  cool  air,  and  by  sponging  the  body  with 
cool  water,  or  vinegar — but  should  there  be  a  disposition  at  this 
time  to  chilliness,  warm  vinegar  or  warm  whiskey  may  be  em- 
ployed ;    for  nbtwithstanding  this  high  temperature,  the   skin 
when  exposed,  is  sometimes  very  sensible  to  the  application  of 
any  substance  below  its  own  heat.     We  need  not,  however, 
always  wait  for  an  appearance  of  moisture  on  the  skin,  before 
we  employ  diaphoretic  remedies;  we  may  have  recourse  to  them 
when  the  violence  of  the  disease  is  so  much  subdued,  as  to  pre- 
sent a  soft  and  yielding  pulse. 

345.  The  nights  of  fever  patients  are,  for  the  most  part,  those 
of  great  restlessness  and  inquietude;  and  the  practitioner  is  much 
importuned  by  the  nurse  or  friends  of  the  patient,  for  "  some- 
thing to  make  him  sleep."     But  beware  how  you  yield  to  this 
request ;  for  an  ill-timed  exhibition  of  opium  in  certain  states  of 
the  remittent  form  of  fever,  is  almost  always  mischievous;  and 


REMITTENT    FEVER.  117 

we  are  sorry  to  add,  has  been  too  often,  fatal.  We  have  seen 
without  doubt,  several  instances  of  heavy  stupor,  and  even  apo- 
plexy, produced  by  even  a  moderate  dose  of  laudanum. 

346.  On  this  account  we  are  extremely  reluctant  to  give  it, 
at  almost  any  period  of  a  remittent;  and  more  especially  to  a 
yellow  fever  patient,  whatever  may  be  the  degree  of  sleepless- 
ness, or  agitation.     Under  such  circumstances,  we  have  found, 
almost  constantly,  that  there  was  either  a  general  or  partial  ac- 
cumulation of  heat,  especially  of  the  head,  a  dry  skin,  bowels 
rather  tardy,  or  very  offensive  evacuations,  to  be  the  cause.     Or 
it  has  been  found  owing  to  a  dull  but  pretty  constant  pain  in  the 
head,  attended  sometimes  by  slight  delirium ;  and  other  times 
with  a  slight  stupor,  alternating  with  distressing  watchfulness, 
l^ulse  either  too  quick  or  lagging. 

347.  In  these  cases,  we  are  certain  that  opium  would  be  in- 
jurious, if  not  fatal.     In  such  cases,  instead  of  it,  we  should  em- 
ploy cold  applications  to  the  heated  parts  of  the  body  and  extre- 
mities, by  sponging;  to  the  head  by  wetted  cloths,  or  a  bladder 
of  cold  water ;  a  few  leeches  to  the  temples ;  a  mild  purge,  as 
castor  oil;  a  free  ventilation  of  the  room,  together  with  a  decided 
reduction  of  the  bed-clothes.     This  mode  of  treatment  is  almost 
sure  to  procure  sleep.  Or  if,  as  has  occasionally  happened,  espe- 
cially in  our  late  epidemic  remittent,  (1828,)  the  feet  and  legs  be 
cold,  to  have  them  well  warmed,  by  a  foot  bath,  or  the  application 
of  dry  heat. 

348.  Affusions  of  cold  water  are  spoken  of  with  high  enco- 
miums by  writers  of  great  practical  eminence  in  this  species  of 
fever — but  we  hesitate  to  recommend  them  in  this  place,  as  their 
usefulness  is  entirely  governed  by  a  particular  state  of  the  system, 
which  it  is  difficult  to  procure  or  to  seize.     It  is  agreed  on  all 
hands,  that  cold  water  applied  to  the  body,  is  an  agent  of  great 
power ;  but  that  it  is  only  useful,  where  the  condition  just  alluded 
to,  exists ;  and  where  all  the  requisites  for  its  exhibition,  can  be 
complied  with.     But  these  conditions  are  so  numerous,  and  so 
difficult  to  designate,  that  few  would  be  tempted  to  employ  this 
remedy,  after  having  heard  them  detailed.     But  independently 
of  these  considerations,  great  inconveniences  attach  to  this  re- 
medy in  private  practice ;  in  hospitals  alone  it  can  be  used  with 
advantage,  for  in  them  every  contrivance  for  its  application  is  at 
hand,  and  ready  at  a  moment's  warning. 

349.  Blisters  are  very  often  advantageously  employed  in  these 
fevers;  but  there  are  few  remedies,  in  the  use  of  which  so  much 
discrimination  is  required.     They  should  never  be  used  in  the 
early  part  of  the  disease ;  that  is,  never  before  the  pulse  is  suffi- 
ciently reduced.     Should  we  use  them  too  early,  they  do  harm 
instead  of  affording  relief — for  there  is  truly  a  "  blistering  point." 


118  REMITTENT    FEVER. 

But  when  the  system  is  properly  prepared,  few  remedies  are  of 
more  decided  efficacy. 

350.  Blisters  are  employed  with  two  views.     1.  To 'relieve 
pain,  by  being  applied  immediately  over,  or  as  near  as  possible 
to  the  part  pained — thus,  when  head-ache  is  severe,  or  delirium 
is  present,  they  are  most  successfully  applied  to  the  nape  of  the 
neck,  and  shoulders;  if  the  pain  be  in  the  chest,  stomach,  or 
side,  they  should  be  applied  to  these  parts  respectively.     2. 
They  are  used  with  a  view  of  making  a  counter-impression,  or 
revulsion.  When  used  for  this  purpose,  they  are  generally  fixed 
upon  the  inside  of  the  calves  of  the  legs,  or  above  the  wrists 
upon  the  arms,  or  upon  both.     We  may  here  remark  upon  the 
use  of  blisters,  that,  to  be  useful,  they  must  be  of  sufficient  size; 
for  we  have  before  observed,  that  a  large  blister  gives  little,  or 
no  more  pain,  than  a  smaller  one;  but  is  much  more  useful.  (See 
par.  132.) 

351.  It  sometimes  happens,  that  remittents  do  not  require,  or 
will  not  bear  large  evacuations,  especially  by  bleeding,  even  in 
this  portion  of  our  country,  but  more  especially  in  the  south — 
this  is  occasioned  by   several   causes;  but  over  neither   have 
we  any  controul.     We  have   already    noticed    this  diversity, 
but  this  will  occasion  very  little  embarrassment  in  practice,  as 
the  character  of  the  disease  will  readily  be  learnt;  1st,  by  the 
state  of  pulse ;  2d,  by  the  greater  or  less  violence  of  the  symp- 
toms; 3d,  by  the  effects  of  remedies;  4th,  by  the  peculiarities  of 
constitution  of  the  patient;  5th,  by  the  general  character  of  the 
other  prevailing  diseases. 

1.  By  the  State  of  Pulse. 

352.  The  pulse  in  fevers  is  a  more  certain  guide  than  in  almost 
any  other  form  of  disease — it  must  therefore  be  strictly  attended 
to,  and  all  its  different  varieties  should  if  possible  be  understood. 
We  shall  endeavour  to  convey  an  idea  of  the  states  of  the  pulse; 
but  are  thoroughly  sensible  of  the  difficulty  which  attends  the 
subject — for  experience  must  do  much  towards  its  being  well 
comprehended.    We  shall  therefore  merely  state  here  the  condi- 
tions of  pulse  which  require  and  justify  the  abstraction  of  blood 
in  fevers,     a.  Where  it  is  hard  and  full.     6.  Where  it  is  preter- 
naturally  slow  or  sluggish,  with  tension  and  firmness,    c.  Where 
it  is  frequent  and  tense,     d.  Where  it  is  quick  and  corded,     e. 
Where  it  is  oppressed  and  labouring.*     Where  either  of  these 

*  The  hardness  of  the  pulse,  is  to  be  ascertained,  by  the  sensation  it  conveys 
to  the  mind  when  felt  by  the  finger.  Hard  and  soft,  are  merely  relative  terms; 
and  are  simple  ideas.  But  an  inference  is  instantly  drawn,  when  the  finger 
touches  a  body;  and  when  the  mind  is  directed  to  determine  its  qualities,  it 


REMITTENT   FEVER.  119 

state  of  pulse  obtains,  we  are  justified,  (if  other  symptoms,  such 
as  pain,  oppression,  delirium,  &c.  be  present,)  to  abstract  blood; 
and  repeat  it,  so  long  as  these  marks  of  disease  continue.  But 
on  the  contrary,  we  are  not  warranted  to  draw  blood  where  the 
pulses  are  in  an  opposite  condition  to  those  we  have  just  stated. 
It,  however,  frequently  happens,  that  we  may  safely  and  advan- 
tageously employ  local  blood-letting,  by  cups  or  leeches,  when 
we  should  not  dare  to  abstract  blood  from  the  arm. 

concludes,  that  it  is  either  hard  or  soft.  But  the  degree  of  either,  is  only  ascer- 
tained, by  a  comparison  with  other  bodies;  or  with  the  same  body,  under  dif- 
ferent circumstances;  thus  heat  and  a  variety  of  other  causes,  may  affect  a  body, 
so  as  to  render  it  comparatively,  harder  or  softer,  when  compared  with  itself. 
So  with  the  artery;  for  causes  may  render  it  capable  of  resisting  the  pressure 
of  the  finger,  to  a  greater  or  lesser  degree.  To  become  acquainted  with  the 
relative  conditions  of  the  pulse,  it  is  very  useful  to  examine  carefully  and  fre- 
quently, the  degree  of  pressure  the  young,  and  adult  artery  will  bear,  in  a  state 
of  acknowledged  health;  and  when  it  is  altered  by  disease,  to  endeavour  to 
detect  the  difference,  by  comparing  the  present,  or  deranged  condition,  with 
the  sensation  it  formerly  excited,  when  it  possessed  its  healthy  tone.  If  it  con- 
vey the  idea  .of  greater  firmness,  it  is  to  be  concluded  that  it  is  harder  than 
natural;  but  if  on  the  contrary,  it  give  the  sensation  of  bearing  less  pressure, 
it  is  to  be  considered  as  softer,  than  the  natural  standard.  You  have  then  pre- 
sented to  you,  a  hard  or  a  soft  pulse.  But  it  may  be  well  to  remark,  there  are 
even  degrees  of  these  two  qualities  of  the  pulse,  but  which  can  only  be  learnt 
by  experience.  A  full  pulse  conveys  the  sensation  of  the  vessel  being  distend- 
ed, or  filled  with  a  fluid,  to  as  great  an  extent  as  it  will  bear:  and  to  such  nicety 
of  discrimination  does  the  experienced  finger  arrive  sometimes,  that  in  the  full 
or  contracted  pulse,  it  can  determine  the  thickness  of  the  arterial  parietes. 

The  preternaturally  slow  or  sluggish  pulse  must  be  determined  by  the  beats 
being  fewer  than  the  natural  standard;  and  giving  the  idea  of  an  unwillingness 
to  perform  its  assigned  duty.  This  pulse  is  more  common  with  such  patients, 
as  have  great  cerebral  determination;  amounting  even  to  coma  sometimes.  The 
tension  of  the  pulse  is  ascertained,  by  imagining  the  artery  to  be  stretched  by 
two  contrary  powers;  and  the  degree  of  force  that  would  be  required,  to  make 
it  depart  from  a  straight  line;  this  state  of  the  artery,  we  believe,  is  always 
hard;  the  mode  of  determining  its  firmness,  we  have  just  explained;  and  it  may 
be  considered  as  synonymous  with  the  "hard  pulse."  The  frequency  of  the 
pulse,  is  determined  by  the  excess  of  strokes  beyond  the  natural  standard,  in  a 
given  time,  this  pulse  may  be  attended  by  tension;  if  so,  it  is  always  hard.  The 
quickness  of  the  pulse  is  determined  by  the  time  it  employs  in  performing  its 
stroke,  and  has  no  relation  to  the  period  which  elapses,  between  the  several 
strokes;  consequently,  is  not  synonymous  with  the  "frequent  pulse"  This  pulse 
may  be  tense,  hard,  or  corded;  for  the  tense,  hard,  or  corded  pulse,  may  be 
looked  upon  as  the  same.  The  oppressed,  or  labouring  pulse;  or  as  it  is  fre- 
quently termed,  the  "depressed  pulse,"  conveys  the  idea,  that  the  artery  is 
raising  a  weight  in  distending  itself,  (that  is,  while  it  is  performing  its  beat,) 
almost  equal  to  its  powers. 

In  attempting  to  convey  an  idea  of  the  different  states  of  pulse,  we  are  fully 
aware  of  its  extreme  difficulty  and  of  the  inadequacy  of  words  to  effect  this: 
we  thought  it  right  however  to  attempt  it — and  if  we  have  been  able  to  make 
an  approach  towards  explaining  of  them,  we  shall  think  we  have  gained  by  it. 


120  REMITTENT    FEVER. 


2.  By  the  Greater  or  Less  Violence  of  Symptoms. 

353.  It  obtains  in  many  instances  of  remittents,  that  very  few 
distressing  symptoms  accompany  it — the  fever,  not  excessive, 
and  the  remissions  strongly  marked ;  head-ache,  or  other  pains, 
very  moderate ;  and  no  delirium.     In  these  cases  it  is  not  neces- 
sary to  bleed  largely. 

3.  By  the  Effects  of  Remedies. 

354.  This  should  always  be  kept  in  view ;  for  the  loss  of  a 
few  ounces  of  blood,  or  other  evacuations,  will  have  a  much 
greater  effect  at  one  time,  than  at  another,  and  upon  different  in- 
dividuals. We  should,  therefore,  apportion  our  remedies  to  their 
effects. 

4.  By  the  Peculiarities  of  Constitution. 

355.  Almost  every  individual  has  peculiarities,  as  regards 
remedies — some  requiring  large,  and  others,  smaller  doses,  of 
even  the  same  medicine.  We  should,  therefore,  always  be  atten- 
tive to  this  peculiarity,  and  act  as  this  will  point  out.   It  is  highly 
important  to  study  the  habits  of  patients,  that  it  may  be  known 
how  they  may  be  effected  by  particular  agents ;  for  many  times 
mischief  would  ensue  without  this  information,  from  the  exhibi- 
tion of  very  common  remedies.     Some  cannot  bear  the  loss  of 
even  a  very  few  ounces  of  blood  without  fainting ;  while  others 
can  bear  their  vessels  almost  drained,  without  such  an  effect  en- 
suing.    But  in  deciding  how  we  are  to  act  in  the  first  case,  it  is 
important  to  know,  that  this  circumstance  does  not  always  justify 
withholding  the  lancet;  but  in  this  case,  much  less  blood  will 
suffice,  than  if  this  did  not  obtain.     Others  cannot  be  affected  by 
certain  remedies,  at  least  in  a  degree  to  be  any  way  useful,  with- 
out much  difficulty — thus  we  have  seen  some  patients  take,  with- 
out effect,  three  or  four  times  the  quantity  that  would  answer  for 
others ;  while,  on  the  other  hand,  we  have  known  some,  so  ex- 
tremely susceptible  to  the  action  of  certain  articles,  that  it  would 
really  be  unsafe  to  exhibit  them  in  almost  any  quantity.     These 
deviations  should  always  be  kept  in  view,  lest  we  should  attribute 
to  the  disease,  that  which  properly  belongs,  to  idiosyncrasy. 

5.   The  Character  of  the  other  Prevailing  Diseases. 

356.  If  it  should  be  at  a  season  of  the  year  when  other  dis- 
eases be  rife,  we  may  learn  much  by  attending  to  their  general 


REMITTENT    FEVER.  121 

character — if  this  should  be  inflammatory,  the  remittents  will 
partake,  to  a  greater  or  less  extent,  of  this  character — on  the 
other  hand,  should  the  contrary  be  their  disposition,  we  must 
employ  less  bleeding,  or  none,  and  more  moderate  purging:  in 
a  word,  a  modified  treatment  will  then  be  required;  which  we 
trust  can  be  learned  by  paying  attention  to  the  general  doctrine 
of  fever. 

357.  That  occult  cause,  which  determines  the  character  of 
every  epidemic,  operates  by  laws,  of  which  we  are  entirely  ig- 
norant; its  power  is  only  made  known  to  us  by  the  peculiarities 
it  imposes  upon  the  prevailing  disease.     These  peculiarities  are 
never  to  be  lost  sight  of.     They  are  of  the  greatest  practical  im- 
portance; since,  the  neglect  or  observance  of  them,  will  render 
the  treatment  either  successful,  or  otherwise.    And  the  fact  can- 
not be  too  early  suggested,  or  too  strongly  enforced,  that  there 
are  shades  of  difference  in  every  disease  of  an  epidemic  charac- 
ter, however  frequently  or  seldom,  it  may  renew  its  visitations. 
This  has  been  well  demonstrated  in  the  various  returns  of  the 
"  yellow  fever"  in  this  city;  and  has  been  no  less  evident  in  the 
recurrences   of  the  intermittent  and  remittent  fevers,  in   the 
neighbourhood  of  Philadelphia,  for  the  last  six,  or  seven  years. 
The  last,  that  is,  the  one  of  1828,  has  in  several  very  important 
particulars,  differed  from  every  preceding  one ;  and,  consequent- 
ly, required  a  difference  in  the  mode  of  treatment. 

358.  When  the  disease  was  of  the  remittent  form,  it  was  fre- 
quently ushered  in  by  a  sense  of  cold,  pretty  long  in  duration, 
rather  than  by  a  manifest  chill.    The  reaction  was  generally  ex- 
cessive, and  constantly  attended  by  severe  head-ache,  and  often- 
times with  delirium.  The  hot  stage  decreased  very  slowly,  and 
sometimes  the  period  of  its  remission  was  marked  by  a  partial 
sweat.     It  observed  almost  constantly  the  tertian  type;  and  the 
third  day  was  sure  to  be  marked  by  an  increased  severity  of  the 
exacerbation.     It  sometimes  required  ample  depletion ;  both  by 
general  and  local  means;  purging  by  the  milder  cathartics;  blis- 
tering, &c. 

359.  Should  the  investigations  just  recommended  lead  to  the 
persuasion  that  the  character  of  the  disease  is  one  of  but  mode- 
rate, or  feeble  excitement,  we  must  be  regulated  in  the  use  of 
remedies  by  this  impression.  But  we  should  not  let  ill-grounded 
fears  so  pervert  our  judgment,  as  to  make  us  plunge  ourselves  into 
the  opposite  extreme.     The  dread  of  a  low,  or  typhus  state,  has 
too  frequently  suspended  the  use  of  the  only  remedies  which 
could  h&  e  prevented  it,  or  saved  the  patient ;  and  thus,  depletion, 
to  a  proper  extent,  has  been  neglected,  or  feared,  and  stimulants 
made  to  usurp  its  place.    Against  an  error  of  this  kind,  we  can- 
not guard  too  carefully;  for  even  typhus,  (as  it  is  called,)  as  we 

16 


122  CONTINUED    FEVER. 

shall  hereafter  say,  can  only  be  cured  by  premised  bleeding 
and  purging.  We  should,  therefore,  never  neglect  these  reme- 
dies when  indicated  in  the  commencement  of  a  disease,  because 
this  disease  may  eventuate  in  the  condition  called  typhus.  It, 
however,  behoves  us  to  watch  carefully  the  tendency  of  the 
fever.  If  it  be  disposed  to  run  into  one  of  feeble  action,  after 
a  few  days  continuance,  we  should  take  care  not  to  push  deple- 
tion beyond  its  proper  bound;  the  pulse,  and  other  symptoms, 
will  direct  us  when  to  withhold  it,  if  properly  studied.  But  it 
must  be  recollected,  that,  when  fever  does  not  require  depletion, 
it  does  not  necessarily  require  stimulation — that  there  is  a  period 
in  such  fevers  as  are  disposed  to  run  into  a  low  state,  at  which 
we  must  withhold  evacuants,  we  grant;  but  we  must  insist,  that 
it  requires  much  judgment  when  to  exchange  them  for  tonics,  or 
stimulants,  should  these  ever  be  necessary. 

360.  There  is  no  term  in  medical  nomenclature,  that  is  so  ill- 
defined,  or  little  understood,  as  typhus;  according  to  our  ob- 
servations, it  is  almost  constantly  made  to  consist  in  a  set  of 
symptoms  that  have  two  opposite  conditions  of  the  system  for 
their  origin;  yet  both  treated  as  if  they  were  one  and  the  same. 
We  shall  attempt  to  prove  this  by  and  by. 

361.  During  the  whole  continuation  of  fever,  too  much  regard 
cannot  be  paid  to  the  articles  of  diet  and  drink ;  we  have  dwelt 
upon  this  in  our  general  observations  on  fever;  and  a  long  ex- 
perience convinces  us,  that  the  rules  laid  down,  cannot  be  dis- 
pensed with,  without  incurring  a  risk  of  mischief  to  the  patient. 

362.  It  will  be  observed,  that  we  have  hitherto  not  prescribed 
that  supposed  innocent  cordial  and  beverage,  "  wine  whey,"  in 
any  one  instance ;  not  even  in  such  cases  as  are  too  generally 
supposed  to  require  it — namely,  where  the  tongue  is  black  or 
brown,  &c.,  we  have  done  this,  from  a  conviction,  that  these 
symptoms  do   not  require  such  a  remedy;  and  which  in  itself 
would  do  mischief,  were  it  employed,  since,  these  very  symp- 
toms are  almost  sure  to  be  removed,  (especially  when  they  ap- 
pear after  the  few  first  days  of  the  disease,)  by  a  contrary  plan ; 
and  when  they  show  themselves  in  long-protracted  fevers,  it  is 
totally  inefficient.  But  more  of  this  by  and  by. 

SECT.  III. — CONTINUED  FEVER. 

363.  This  form  of  fever,  allows  us  but  little  to  say  in  parti- 
cular; as  it  is  one  that  rarely  appears  among  us,  unmixed  with 
symptoms,  that  belong  to  the  remittent  of  this  climate.  Zye  have 
of  late  years  paid  some  attention  to  this  form  of  fever ;  because 
it  is  recognised  by  almost  all  the  writers  upon  this  subject,  and 
made  by  some  to  be  essentially  different  from  the  remittent.  We 


CONTINUED    FEVER.  123 

have  however,  never  satisfied  ourselves,  that  there  is  good 
grounds  for  such  a  distinction ;  at  least  so  far  as  it  is  just  to  con- 
sider similar  remote  causes. 

364.  The  continued  fever  runs  its  course,  without  intermis- 
sions, and  with  but  very  slight  remissions.     Good  makes  this 
fever,  consist  of  ''one  series  of  increase,  and  decrease;  with  a 
tendency  to  exacerbation  and  remission,  for  the  most  part  ap- 
pearing twice  every  twenty-four  hours." — Study  of  Med.  Vol. 
II.  p.  116.  Amer.  edit.*  He  divides  it  into  three  species;  1,  in- 
flammatory fever ;  2,  typhus  fever ;  3,  synochal  fever. 

365.  For  the  purpose  of  practice,  this  division  into  species  is 
not  essential;  for  the  duration  and  force,  of  the  inflammatory 
symptoms,  are  altogether  uncertain ;  for,  the  continuance,  and 
perhaps  existence  of  this  condition  of  the  system,  will  depend 
upon  the  power  of  the  remote  cause  or  causes;  constitution  of 
the  patient ;  location  ;  and  the  mode  of  treatment.   If  the  inflam- 
matory symptoms  are  high,  we  have  the  first  species,  or  the  in- 
flammatory fever;  but  if  they  be  not  high,  yet  will  bear  mode- 
rate depletion,  the  synochal  fever  may  be  considered  as  present; 
and  if  the  reduction  of  the  phlogistic  state  be  still  more  evident, 
typhus  according  to    some  writers   and  practitioners,  will  be 
formed.     So  that  the  three  species  of  Good,  may  consist  only  of 
modifications  of  his  continued  fever;  and  these  forms  be  de- 
pendent upon  the  contingencies  above  named. 

366.  Thus  it  would  appear,  that  the  same  remote  cause  or 
causes,  may  produce  the  three  species  of  continued  fever  of  Good, 
in  different  individuals;  or  they  may  follow  each  other  in  the 
same  person,  from  the  same  remote,  and  exciting  causes. 

367.  This  form  of  fever,  commences  like  most  other  fevers; 
that  is,  with  languor,  or  a  feeling  of  weakness;  indisposition  to 
motion;  yawning  and  stretching;  paleness,  or  shrinking  of  the 
extremities;  rarely  a  well-defined  chill;  but  at  first,  a  sensation 
is  felt  down  the  back,  as  if  cold  water  were  poured  upon  it,  which 
sometimes  extends  to  the  whole  body ;  head-ache ;  red  eyes ; 
disagreeable  taste  in  the  mouth ;  loss  of  appetite ;  pain  in  the 
back  and  loins,  with  a  short  breathing. 

*  In  what  does  this  definition  of  continued  fever  differ  from  that  of  our  ordi- 
nary remittent?  in  the  mere  circumstance  of  the  latter  being  "strikingly  ex- 
acerbating and  remitting."  Good,  vol.  2d,  p.  21.  Does  this  mark  any  essential 
difference  between  the  two,  except  what  may  be  purely  accidental,  or  de- 
rived from  the  previous  state  of  the  system  ?  for  we  have  seen  remittents,  pro- 
perly so  called,  have  "one  series  of  increase,"  and  with  very  little  tendency  to 
marked  exacerbation  or  remission.  Indeed,  in  a  practical  point  of  view,  but 
little  is,  or  can  be  gained  by  distinctions,  without  essential  differences.  For 
our  curative  intentions  are  derived  from,  (or  always  should  be,)  the  state  of  the 
circulatory  and  nervous  systems;  and  not  from  the  period  of  exacerbation,  or 
the  time  of  remission,  or  the  one  being  more  intense,  and  the  other  a  little 
more  perfect.  The  remote  causes  appear  to  be  the  same. 


124  CONTINUED    FEVER. 

368.  These  symptoms,  after  a  shorter  or  longer  time,  are  fol- 
lowed by  a  glow  or  heat  over  the   whole  body ;  flushed  face ; 
anxious  expression  of  the  eye';  restlessness;  increased  head-ache, 
perhaps  delirium;  oppression  about  the  precordia;  nausea,  and 
sometimes  vomiting  of  pure  bilious  matter;  red  eyes;  and  very 
dry  skin ;    bowels    almost    always   constipated;    deficiency  of 
urine,  &c. 

369.  The  pulse,  not  extremely  frequent;  rarely  amounting  to 
a  hundred  in  the  beginning  of  the  disease;  but  may  rise  to  one 
hundred  and  twenty  as  it  progresses ;  always  hard  and  full,  re- 
sisting a  considerable  compressing  force. 

370.  The  causes  of  this  fever,  are  bodily  fatigue  ;  great  men- 
tal exertion ;  anxiety ;  long  watching  ;  passions  and  emotions  of 
the  mind ;  cold  long  applied  to  the  body  ;  checked  perspiration; 
&c.  &c. *  (marsh  miasma?)     Some  of  the  British  writers  con- 
sider this  fever  as  contagious ;  but  there  is  not  the  slightest 
•ground  for  this  belief;   at  least  in  this  country.     Marsh  miasma 
and  excessive  heat  however,  may  be  looked  upon  as  the  most 
frequent  causes  in  autumn. 

371.  The  exacerbations  of  this  fever  are  almost  always  in  the 
'  evening;  in  the  morning  an  abatement  of  the  frequency  of  the 

pulse ;  a  diminished  temperature  of  the  skin,  and  a  partial  or  ge- 
neral attempt  at  a  solution  of  the  paroxysm  by  sweat  may  be  ob- 
served. But  this,  when  not  complete,  is  of  short  duration ;  for  the 
fever  becomes  again  very  quickly,  and  sometimes,  greatly  aug- 
mented. 

372.  If  this  fever  continue  beyond  the  fifth  or  sixth  day,  with- 
out a  tendency  to  amendment  or  crisis,  we  for  the  most  part  find 
the  strength  of  the  patient  fail  with  considerable  rapidity ;  the 
pulse  to  increase  in  frequency ;  but  is  weaker,  smaller,  and  per- 
haps irregular.     The  mind  becomes  more  certainly  unsettled ; 
the  tongue  may  now  be  dry;  or  brown,  with  a  tenacious  mois- 
ture; the  heat  of  the  body  irregularly  diffused ;  some  portions 
more  than  ordinarily  hot,  as  the  head,  chest,   abdomen,  and 
back;  while  the  hands  and  arms;  and  the  legs  and  feet,  are  pre- 
ternaturally  cold.     Now  and  then,  a  cold  sweat  bedews  the 
whole  body;  or  it  stands  in  detached  portions,  upon  the  marble- 
cold  skin. 

373.  The  urine  for  the  most  part,  is  of  a  very  high  colour, 
and  scantily  secreted  ;  or  it  may  be  unusually  abundant,  of  watery 
transparency,  and  without  a  deposition.     This  fever,  as  noticed 

*  These  are  the  common  causes  assigned  for  the  production  of  continued 
fever — we  should  regard  them  in  general  as  but  the  exciting  causes.  Marsh 
miasma  may,  we  know,  remain  dormant  in  the  system  for  along  time — so  long 
indeed  in  some  instances  as  to  be  lost  sight  of,  though  it  was  the  veritable  re- 
mote cause  of  the  disease. 


CONTINUED    FEVER.  125 

above,  may  degenerate  into  what  is  commonly  called  typhus ; 
and  it  may  pass  off  in  an  intermittent  form.  From  this  it  ap- 
pears, that  it  differs  but  little  in  essentials,  from  the  common  re- 
mittent; and  this  variation  may  be  looked  upon,  rather  as  acci- 
dental, than  necessary  or  constant.  Location  perhaps  may  have 
considerable  influence  in  modifying  the  type  of  this  form  of  con- 
tinued fever:  as  it  is  found  most  frequently  in  marshy  and  wet 
situatfons.  It  was  very  frequently  met  with  in  the  epidemic  of 
the  fall  of  1828. 

374.  This  fever  differs  from  the  ordinary  form  of  the  remit- 
tent common  to  our  country,  principally  in,   1st,  the  exacerba- 
tions being  less  regular;  2d,  the  remissions  more  obscure,  or  less 
tendency  to  useful,  or  critical  perspiration;  3d,  greater  discharges 
of  pure  bile;  4th,  less  equality  in  the  general  temperature  of  the 
body ;  5th,  more  decided  tendency  in  the  extremities,  to  become 
cold;  6th,  cold  colliquative  sweats;  stronger  disposition  to  deli- 
rium; and  a  dry  state  of  the  tongue.  But  all  these  variations  are 
merely  modifications  of  force,  in  the  disease. 

375.  The  favourable  signs  in  this  fever,  are  a  more  equal  dif- 
fusion of  heat;  a  tendency  to  a  general,  warm  perspiration;  di- 
minished frequency  of  pulse;  less  restlessness  of  body;  more 
clearness,  and  steadiness  of  mind ;  tongue  changing  its  dark,  to 
a  light,  moist  coat ;  diminished  thirst ;  the  free  secretion  of  a 
urine,  that  will  yield  a  deposit  of  a  brick-dust  colour ;  and  some- 
times a  diarrhoea. 

376.  The  unfavourable  signs  are  irreclaimably  cold  extremi- 
ties ;  a  profuse  cold  sweat,  either  general,  or  partial ;  increased 
frequency  of  the  pulse,  with  an  abatement  of  its  strength  ;  great 
jactitation;  muttering  low  delirium;  picking  of  the  bed-clothes; 
twitching  of  the  nerves ;  increase  of  dryness  of  the  tongue,  and 
blackness  of  the  teeth;  hiccup;  a  suppression  of  urine ;  and  above 
all,  the  patient  not  feeling  the  necessity,  or  possessing  the  abi- 
lity, to  retract  the  tongue,  after  it  has  been  thrust  beyond  the 
teeth,*  for  the  purpose  of  examination  ;  involuntary  stools ;  apo- 
plexy ;  convulsions ;  death. 

377.  The  mode  of  treatment  of  this  fever  is  very  analogous  to 
that  of  the  remittent,  of  which  we  have  already  spoken.     The 
nature  and  extent  of  the  remedies  will  in  great  measure  de- 
pend upon  the  force,  and  period  of  the  disease.     If  in  the  com- 
mencement, while  the  pulse  manifests  vigour  and  activity  in  the 
vascular  system  ;  and  especially,  if  much  head-ache  be  present, 
we  must  resort  to  bleeding,  to  an  extent  that  will  insure  an 

*  We  have  been  very  attentive  to  this  symptom  for  the  last  few  years;  and 
so  far,  we  have  not  seen  a  recovery,  where  it  had  existed. 


126  CONTINUED    FEVER. 

abatement  qf  the  head-ache,  and  a  decided  reduction  of  the 
pulse.  We  cannot  determine  by  figures,  the  number  of  ounces 
that  should  be  taken;  the  effects  above  stated,  as  necessary  to 
take  place  from  the  bleeding,  should  alone  be  the  guide,  both  as 
regards  the  quantity,  as  well  as  for  the  repetition  of  the  opera- 
tion. If  the  loss  often  ounces,  or  even  less,  produce  the  changes 
insisted  on,  the  blood  may  be  stopped ;  but  if  several  ounces 
more  are  required  for  this  end,  they  must  be  drawn. 

378.  If  there  be  less  vigour  of  pulse,  or  so  little  as  not  to  jus- 
tify the  drawing  of  blood  from  the  arm,  either  from  its  having 
been  reduced  by  a  previous  bleeding,  or  from  any  other  cause, 
it  may  be  abstracted  by  leeches,  or  cupping;  from  the  head,  if 
this  part  be  acknowledged  the  seat  of  pain ;  or  if  there  be  deli- 
rium, or  stupor,  a  flushed  face,  and  loud  breathing,  it  should 
also  be  done.     If  there  be  much  heat  in  the  head,  cold  applica- 
tions must  not  be  omitted. 

379.  Should  there  be  pain,  or  even  considerable  tenderness 
upon  pressing  the  region  of  the  stomach,  after  depleting  as  above 
directed ;  or  where  there  is  no  great  embarrassment  in  the  head, 
four  or  five  ounces  of  blood  should  be  drawn  from  over  the  pit 
of  the  stomach,  by  the  same  means. 

380.  The  alimentary  canal  must  now  be  evacuated,  after  the 
same  manner  as  has  been  directed,  at  page  81 ;  and  should  these 
means  produce  a  tendency  to  perspiration,  it  should  be  encou- 
raged by  drinking  of  warm,  weak  lemonade,  baum  tea,  or  weak 
common  tea.     Should  these  means  have  been  faithfully  followed 
in  the  beginning,  it  will  rarely  be  necessary  to  repeat  them.  But 
should  the  symptoms  continue,  and  the  pulse  still  be  full  and 
active,  the  lancet,  and  other  evacuations  must  again  be  resort- 
ed to. 

381.  If  the  feet  become  cold,  they  should  not  be  permitted  to 
remain  so  a  moment  longer  than  proper  applications  can  be  made 
to  them.     These  applications  may  be  warm  vinegar  and  mustard, 
or  heated  bricks;  jugs  of  warm  water,  or  the  fqet  placed  in  a  pail 
of  warm  water,  in  which  salt,  or  mustard,  is  mingled.  The  first 
is  to  be  preferred  when  the  system  appears  rather  prostrated ; 
and  they  should  be  suffered  to  remain  on,  until  they  produce 
redness,  and  pain.  The  second,  where  the  coldness  is  temporary, 
and  where  the  action  of  the  skin  is  easily  excited:  and  the  third, 
when  there  is  head-ache,  delirium,  and  great  restlessness. 

382.  During  the  continuance  of  the  fever,  the  bowels  are  to  be 
kept  free  after  the  first  or  second  day,  by  the  more  mild  purga- 
tives ;  such  as  the  castor  oil,  magnesia  and  salts ;  rhubarb  and 
magnesia;  Rochelle  salts,  and  the  Seidlitz  powders.    Should  the 
evacuations,  however,  become  very  dark-coloured  without  odour, 


CONTINUED    FEVER.  127 

or  very  offensive,  with  a  frequent  inclination  to  use  the  pan  with- 
out much  passing  from  the  bowels  at  a  time,*  small  doses  of  ca- 
lomel should  be  given,  and  continued,  until  they  procure  a  change 
in  the  appearance,  odour,  and  quantity  of  the  feces.t 

383.  Should  the  bowels  not  be  speedily  or  sufficiently  obe- 
dient to  the  medicines  exhibited,  but  become  painful  and  tumid, 
they  should  be  excited  to  discharge  themselves  by  means  of  a 
simple  injection.  J     If  the  stomach  become  very  sick,  and  throw 
up  bile,  twenty  grains  of  ipecacuanha  should  be  given  in  a  table* 
spoonful  of  lukewarm  water ;  and  its  operation  encouraged  by 
draughts  of  warm  water.     But  if  the  stomach  be  merely  sick,  or 
rejects  a  colourless,  or  a  pea-green  fluid,  the  emetic  should  not  be 
given;  especially,  if  there  be  a  tendency  to  dryness  of  the  tongue, 
or  much  tenderness  at  the  pit  of  the  stomach. 

384.  Blisters  are  highly  useful  at  a  certain  period  of  this  fever, 
that  is,  after  the  more  active  and  inflammatory  stage  has  passed. 
At  this  time,  if  there  be  a  disposition  in  the  feet  and  legs  to  be- 
come cold ;  if  the  remissions  continue  to  be  obscure ;  if  there  be 
no  disposition  in  the  skin  to  furnish  a  warm,  gentle,  and  general 
perspiration ;  a  tendency  of  the  tongue  to  become  dark  and  dry; 
blisters  should  be  applied  to  the  calves  of  the  legs,  and  suffered 
to  remain  until  they  irritate  the  skin  in  a  decided  manner.   This 
will  be  ascertained  by  the  patient  complaining  of  pain ;  and  by 
the  inspection  of  the  parts  to  which  the  blisters  were  applied. 
But  should  they  neither  have  drawn,  nor  have  reddened  the  skin, 
they  should  be  kept  on  until  either  of  these  changes  take  place; 
we  say  either,  for  if  they  have  blistered,  nothing  more  can  be 
expected ;  or  if  they  have  well  reddened  the  surface  on  which 
they  have  been  applied,  vesication  will  be  sure  to  follow,  if  the 
part  be  dressed  with  basilicon  ointment.     (See  Art.  Basilicon 
Ointment.) 

385.  These  applications  may  be  repeated  if  the  disease  persist 
in  its  course;  or  if  the  system  appears  reluctant  to  produce  a 

*  Great  mischief  is  sometimes  done,  when  this  state  of  bowels  exists,  by  the 
exhibition  of  laudanum,  or  other  astringents,  with  a  view  to  arrest  their  mo- 
tions; nothing  can  be  more  ill-judged  than  this.  For  it  is  every  way  certain, 
that  this  condition  of  the  bowels  arises  from  putrid  bile,  or  other  offensive 
matters,  which  have  been  thrown  into  the  alimentary  canal,  and  which  require 
to  be  carried  off  by  calomel  and  other  purgatives. 

f  A  grain  of  calomel  should  be  given  every  hour,  until  five  or  six  grains  are 
taken;  if  these  do  not  operate  freely,  let  an  half  ounce  of  castor  oil  be  given; 
and  should  this  not  produce  the  desired  effect  in  two  hours,  let  it  be  repeated. 
Or  should  the  oil  be  offensive  to  the  stomach,  two  or  three  tea-spoonfuls  of 
calcined  magnesia  may  be  given.  Under  the  circumstances  above  described, 
the  purging  should  be  continued  until  this  dark  and  offensive  matter  be  re- 
moved; this  will  be  known  by  a  change  of  appearance  in  the  evacuations. 

£  For  this  purpose,  one  of  the  best  is  a  pint  of  warm  water,  and  a  table-spoon- 
ful of  table  salt. 


128  CONTINUED    FEVER. 

crisis,  either  by  the  skin,  or  by  the  bowels.  If  a  crisis  take  place 
by  the  skin,  the  transpiration  will  be  general ;  more  or  less  pro- 
fuse; the  skin  will  become  cooler,  but  still  a  little  warm  ;  that  is, 
rather  above  the  natural  temperature;  thirst  will  diminish;  the 
head  will  be  relieved;  delirium,  if  it  had  been  present,  will  abate; 
and  the  pulse  become  less  frequent,  more  full,  and  softer.  If  by 
the  bowels,  the  same  reduction  of  the  unpleasant  symptoms  will 
take  place,  with  the  exception  of  the  state  of  the  skin ;  this  will 
not  transmit  so  much  fluid,  though  it  will  be  inclined  to  moisture; 
and  the  reduction  of  its  heat  will  not  be  so  rapid. 

386.  But  if  neither  of  these  events  happen,  a  pair  of  blisters 
to  the  arms  may  be  of  great  importance.     Or,  if  the  tenderness 
remain  at  the  pit  of  the  stomach,  abstracting  three  or  four  ounces 
of  blood  by  leeches,  will  sometimes  produce  the  desirable  changes 
above  stated,  in  a  very  short  time. 

387.  We  do  not  think  that  Dr.  Good  has  followed  the  most 
natural  arrangement  for  his  three  species  of  continued  fever. 
The  typhus  and  the  synochus  should  have  changed  places — at 
least  it  would  be  so  in  this  country.     We  shall,  therefore,  follow 
the  latter  arrangement. 

Synochus  Form. 

388.  The  synochus  fever  does  not  differ  from  the  one  just  de- 
scribed, in  either  its  causes,  or  its  general  phenomena.  The  only 
essential  difference  that  can  be  detected,  is  perhaps  a  lesser  de- 
gree of  inflammation.     With  this  in  view,  the  treatment  will  be 
as  easily  conducted  as  the  one  just  noticed.     It  will  be  proper, 
however,  to  bear  in  mind  the  following  modifications  of  the  prac- 
tice detailed  above. 

389.  First.  That,  as  there  is  less  inflammatory  action  in  this 
form  of  the  disease,  a  smaller  quantity  of  blood  will  be  required 
to  be  drawn. 

390.  Second.   That  the  want  of  vigour  of  the  arterial  system 
may  be  such,  as  to  render  bleeding  from  the  arm  altogether  un- 
necessary, or  even  improper. 

391.  Third.  Though  this  may  be  true  in  some  instances  as 
regards  general  bleeding,  still,  it  hardly  ever  occurs,  that  the  to- 
pical abstraction  of  blood  is  not  absolutely  necessary- — for,  where 
there  is  head-ache,  red  eyes,  flushed  cheeks,  a  hot  skin,  and  per- 
haps delirium,  blood  taken  from  the  temples,  by  leeches,  or 
cupping,  forms  an  essential  part  of  the  treatment. 

392.  Fourth.  If,  under  such  circumstances,  there  be  tender- 
ness at  the  pit  of  the  stomach,  nausea,  and  vomiting  of  thin  fluids, 
or  glairy  mucus,  the  blood  should  be  abstracted  from  the  tender 
part,  by  either  leeches,  or  cups. 


CONTINUED    FEVEK.  129 

393.  Fifth.  Though  the  system  may  permit  only  a  moderate 
expenditure  of  blood,  yet  the  bowels  will  almost  constantly  re- 
quire to  be  free ;  the  extent,  however,  to  which  purging  must 
be  carried,  will  very  much  depend  upon  the  appearances  of  the 
evacuations  themselves ;  recollecting,  that  while  the  stools  are 
dark,  offensive,  and  bilious,  the  bowels  should  be  kept  constantly 
open  by  the  milder  purgatives,*  and  the  occasional  employment 
of  calomel,  after  the  manner  already  directed. 

394.  Sixth.  That  the  purging  must  be  withheld,  for  a  time,  if 
the  stools  are  very  sparing,  watery,  and  mixed  with  the  white 
mucus  of  the  bowels,  or  blood;  or  urged  less  freely,  if  bile  of  a 
healthy  bright  yellow  could  appear. 

395.  Seventh.   Should  the  skin  continue  to  be  dry,  and  hot; 
if  the  pulse  be  frequent,  and  even  but  moderately  tense,  the  neu- 
tral mixture,  with  tartar  emetic,  should  be  given  every  two 
hours;  (see  par.  342,)  provided  the  stomach  is  not  nauseated,  or 
too  irritable,  to  bear  the  tartar  emetic.    In  this  case,  the  neutral 
mixture  alone  should  be  administered.     The  application  of  blis- 
ters will  be  regulated  by  the  rules  laid  down  above. 

396.  In  this,  as  well  as  in  every  other  form  of  continued 
fever,  much  benefit  may  be  derived  from  sponging  the  body  with 
cool,  or  cold  water,  whenever  the  skin  is  hot ;  provided  there  be 
no  moisture  upon  the  surface  at  the  time,  or  no  cough,  or  other 
pneumonic  symptoms,  as  has  already  been  directed  under  the 
head  of  "  Remittent  Fever,"  page  110. 

397.  During  the  whole  course  of  the  disease,  the  diet  should 
be  strictly  antiphlogistic;  and  the  drinks  the  same  as  before  re- 
commended. (See  par.  314.) 

*  There  is  no  practical  error  greater,  than  to  suppose  there  is  a  necessity  of 
employing  the  most  active  purgatives,  in  the  treatment  of  fevers.  As  the 
bowels  are  sometimes  tardy,  and  as  the  relief,  when  this  reluctance  is  over- 
come, is  both  striking  and  salutary,  it  has  been  imagined,  that  the  more  cer- 
tainly, and  speedily,  this  could  be  effected,  the  better  for  the  patient;  hence 
the  almost  universal  use  of  the  drastic  purgatives,  as  calomel  and  jalap;  senna; 
scammony;  gamboge,  &c.  &c.  Now,  let  it  be  again  repeated,  that  in  all  fevers 
there  is  a  constant  liability,  (if  it  does  not  always  exist,)  of  the  mucous  mem- 
brane of  the  stomach  and  bowels  to  become  inflamed;  and,  consequently,  that 
all  irritating  substances  must  be  highly  prejudicial  to  this  condition  of  this  very 
important  surface.  This  is  not  a  refinement  in  doctrine;  nor  an  instance  of 
pathological  theorizing;  it  is  a  constant,  and  valuable  practical  fact,  and  must 
never  be  lost  sight  of.  The  evidence  of  the  mischievous  effects  of  the  drastic 
purgatives  might  be  constantly  observed,  were  practitioners  as  attentive  as  they 
should  be  to  the  phenomena  presented  by  an  inflamed,  or  highly-irritated  mu- 
cous membrane.  For  they  might  see  the  mucus  of  the  intestines  coming  away 
in  quantities,  with  little  or  no  fecal  matter;  and  thus  giving  evidence,  that  the 
mucous  membrane  was  severely  irritated;  in  this  case  the  discharges  may  be 
either  marked  with  streaks,  or  accompanied  by  a  greater  or  less  quantity  of 
blood;  or  when  this  coat  is  inflamed,  they  might  witness  profuse,  watery  dis- 
charges— let  either  of  these  signs  be  a  warning,  not  to  employ  active  medicines, 
or  indeed  a  caution  to  withhold  every  kind,  for  a  while. 

17 


130  CONTINUED   FEVER. 


1  Typhus  Form.  * 

398.  The  typhus  species,  of  continued  fever,  seems  to  be  al- 
together misplaced,  if  it  be  looked  upon  as  a  consequence  of  in- 
flammatory fever.     For  a  typhus  fever,  properly  so  called,  may 
be  regarded,  as  a  distinct  and  peculiar  form  of  fever;  for  it  has 
not  the  same  general  causes  for  its  production;  it  does  not  exhi- 
bit the  same  phenomena;  nor  does  it  yield  exactly  to  the  same 
mode  of  treatment. 

399.  The  form  of  fever  which  we  are  now  to  consider,  de- 
pends for  its  existence  upon  a  state  of  previous  high  excitement, 
and  is  always  a  consequence  of  that  condition.     And  though  it 
shows  a  number  of  symptoms,  extremely  analogous  to  an  origi- 
nal typhus,  yet  it  does  not  bear  with  success  the  same  kind  of 
treatment,  if  we  are  to  credit  the  cases  of  many  of  the  European 
writers.   (See  Sect,  on  Typhus.) 

400.  We  consider  the  typhus  tendency  after  an  inflammatory 
or  even  the  synochus  fever,  to  be  altogether  contingent;  at  least 
we  have  never  seen  an  instance  in  which  we  thought  it  was  ab- 
solutely and  essentially  consequent.    We  have  been  called  upon 
to  witness  this  state  of  the  system,  where  the  disease  had  previ- 
ously been  either  neglected  or  badly  treated;  but  we  can  with 
the  most  perfect  truth  declare,  that  this  condition  has  never  hap- 
pened in  our  hands,  where  the  patient  was  under  our  care  in  the 
early  stage  of  his  disease,  or  where  our  plan  of  treatment  has  not 
been  interrupted,  by  the  improper  interference  of  friends — that 
is,  we  never  have  seen  in  our  practice,  that  state  of  fever  called 
typhus  by  many,  and  which  agreeably  to  them,  requires  stimu- 
lation for  its  cure,  but  under  the  circumstances  just  named. 

401.  We  are  perfectly  persuaded  from  long,and  carefully  made 
observation,  that  the  fever  almost  universally  called  typhus,  is, 
for  the  most  part,  of  artificial  origin  ;t  and  further,  that  it  is  con- 
stantly in  the  power  of  improper  management  to  convert  the 
most  inflammatory  fever  into  this  much-dreaded  state  of  the  sys- 


•  We  are  perfectly  aware  of  the  impropriety  of  this  term  in  this  place;  (see 
Sect,  on  Typhus,)  but  we  make  use  of  it  because  it  is  familiarly  employed  in 
this  country  to  denote  the  state  of  the  system  now  to  be  described.  And  were 
we  to  reject  it  for  a  more  appropriate  term,  we  fear  the  condition  of  the  sys- 
tem about  to  be  noticed,  would  be  less  vividly  conveyed  to  the  mind  of  the 
reader,  who  had  become  familiar  with  the  appearances  in  question,  and  who 
had  been  in  the  habit  of  regarding  this  state  of  fever,  as  a  real,  or  genuine  ty- 
phus. 

•j-  We  may  with  much  propriety  call  the  cases,  now  under  consideration,  that 
is,  such  as  have  been  neglected  in  the  early  stage  of  the  disease,  "accidental 
typhus,"  since  we  have  agreed  to  retain  the  term  typhus,  for  the  reasons  just 
stated. 


CONTINUED    FEVER.  131 

tern;  and  this  by  the  most  simple  and  easy  process  imaginable. 
To  effect  this  terrible  change,  for  such  it  really  is,  it  is  only  ne- 
cessary to  deplete  insufficiently;  or  to  over-stimulate,  during  the 
phlogistic  state  of  the  system. 

402.  What  we  have  just  advanced,  we  believe  to  be  most 
strictly  true;  and  this  convertibility  being  observed  in  this  dis- 
ease, though  it  had  an  artificial,  or  contingent  cause,  it  has  been 
mistaken  for  an  inevitable  consequence ;  to  guard  against  which, 
means  are  employed,  which  only  hastens,  and  makes  sure,  the 
evil.  A  dry,  dark  tongue ;  a  hot  skin;  a  flushed  face ;  a  tendency 
to  delirium;  and  an  irritated  pulse,  are  sure  to  be  called  typhus, 
and  is  too  constantly  treated  as  a  disease  of  absolute  weakness. 
Stimulating  and  tonic  remedies  are  resorted  to,  and  the  system 
is  goaded  into  gangrene,  and  the  patient  into  the  grave,  in  the 
course  of  a  short  time. 

403.  Now,  we  are  of  opinion,  that  the  above-named  train  of 
symptoms  do  not  constitute  typhus  fever,  in  its  true  meaning, 
though  typhus,  has  all  of  them  as  attendant  symptoms;  for  they 
will  seldom,  or  never  yield  to  the  stimulant  plan  of  treatment; 
while  we  are  told,  and  perhaps  bound  to  believe,  by  the  greater 
part  of  the  writers,  that  typhus  is  sometimes  cured  by  bark, 
wine,  volatile  alkali,  &c.  (See  Sect,  on  Typhus.) 

404.  Our  experience  is  decidedly  against  this  mode  of  prac- 
tice ;  for  we  have  not  unfrequently,  when  called  upon   to  pre- 
scribe for  this  artificial   disease,  witnessed  that  it  would  yield, 
with  pretty  constant  certainty,  to  a  perseverance  in  the  antiphlo- 
gistic and  temporizing  plan  of  treatment.     We  have  often  ab- 
stracted blood,  both  from  the  general  system,  as  well  as  topical- 
ly, when  all  the  symptoms  enumerated,  and  which  are  supposed 
to  constitute  typhus,  were  present ;  and  we  have  witnessed  them 
to  change  their  aspects  immediately.     For  by  these  means,  we 
have  had  the  dry  dark  tongue  changed  to,  (sometimes  in  the 
course  of  an  hour,)  a  moist,  whitish  one ;  for  the  dry,  hot  skin, 
we  have  had  a  cool,  moist  one ;  for  the  flushed  face,  we  have  had 
a  pale  one;  delirium  has  been  arrested;  and  the  irritated  pulse, 
has  been  converted  into  one  of  a  mild,  and  open  character. 

405.  One  of  the  most  dangerous  errors  in  the  practice  of  me- 
dicine, in  prescribing  for  the  name  of  the,  disease,  instead  of  at-  ( 
tending  to  the  state  of  the  system — that  is,  paying  a  strict  atten-  | 
tion  to  the  state  of  the  pulse;  the  degree,  and  seat  of  pain;  and 
the  state  of  skin.     For  if  the  pulse  be  tense  and  active ;  pain 
acute;  especially,  in  the  head,  chest,  or  region  of  the  stomach; 
the  skin  hot,  and  dry;  the  tongue  dry;  the  teeth  encrusted,  and 
the  mouth  black ;  the  fingers  employed  in  picking  the  bed-clothes, 
or  the  arms  twitching  with  subsultus  tendinum,  we  do  not  hesi- 
tate to  abstract  blood  in  one  way  or  other,  be  the  period  of  the 


132  CONTINUED    FEVER. 

disease  what  it  may.  In  this  I  am  supported  abundantly  by  Dr. 
Tweedie.  "  When  the  pulse  was  sharp,  and  the  eye  injected, 
notwithstanding  apparent  prostration,  and  a  dry  brown  coating 
on  the  tongue,  I  have  seen  a  few  ounces  of  blood  from  the  arm 
of  very  great  benefit.  Stimulants  under  such  circumstances  are 
always  injurious,  and  generally  render  the  situation  of  the  pa- 
tient quite  hopeless."  "I  am  convinced  that  such  symptoms 
are  frequently  brought  on  from  the  neglect  of  early  evacuations, 
and  the  cooling  treatment  in  the  beginning  of  the  disease." 
Tweedie's  Illustrations,  pp.  166, 167.  We  would  especially  di- 
rect the  young  practitioner's  attention  to  these  declarations  olfDr. 
Tweedie,  as  it  may  correct  no  uncommon  error  of  medical  edu- 
cation. 

406.  Nor  would  this  be  all;  we  would  purge  as  just  directed, 
(page  81,)  and  observe  a  rigid  antiphlogistic  regimen  through- 
out.    We  would  do  this,  because  we  could  appeal  to  our  experi- 
ence for  the  comparative  success  of  the  two   methods;  for  the 
time  was,  when  we  went  with  the  current ;  stimulated  as  fear- 
lessly as  any  one ;  and  lost  patients  as  certainly  as  any  other 
practitioner.     But  for  many  years  past  we  have  abandoned  this 
mode  of  treatment;  and  by  doing  so,  if  we  do  not  deceive  our- 
selves, we  have  carried  patients  through,  that  would,  we  sin- 
cerely believe,  have  succumbed  under  the  other  plan. 

407.  If  then,  we  have  the  misfortune  to  meet  with  this  artifi- 
cial disease,  we  treat  it,  as  if  there  were  still  a  lurking  inflamma- 
tion present  in  some  one  of  the  viscera;  or  as  if  the  morbid  irri- 
tation of  the  pulse  could  only  be  subdued  by  a  sedative,  or  tran- 
quillizing mode  of  treatment.     That  is,  by  aperient  medicine, 
the  (perhaps)  loss  of  blood ;  a  mild  regimen,  and  the  total  ab- 
straction of  all  stimuli,  either  in  the  form  of  food,  or  medicine; 
if  we  except  the  occasional  employment  of  blisters;  or  now  and 
then,  perhaps  the  use  of  laudanum.  To  be  successful  therefore 
in  this  state  of  fever,  only  requires,  that  the  evacuations  should 
be  suited  to  the  condition  of  the  system,  for  evacuants  must  be 
employed. 

408.  But  let  us  not,  however,  be  understood  to  insinuate,  that 
no  recoveries  take  place  under  the  stimulant  plan  of  treatment ; 
for  certainly  there  have  been  instances  of  this  kind,  if  we  are  to  be- 
lieve practitioners ;  so  there  have  been  escapes  from  shipwreck, 
or  the  carnage  of  battle ;  or  from  the  deadly  plague  itself,  under 
the  most  preposterous  treatment  possible,  or  under  no  treatment 
whatever.     But  can  any  one  flatter  himself,  that  the  recovery  of 
a  patient  from  typhus  after  the  use  of  stimulants,  is  an  instance 
of  the  triumph  of  remedies?     Have  not  the  natural  energies  of 
the  system  done  most  in  effecting  the  cure? 

409.  Let  us  now  consider  the  state  of  the  system ;  while  la- 


CONTINUED    FEVER.  133 

bouring  under  a  fever  so  commonly,  though  so  wrongly,  called 
typhus;  and  in  doing  so,  let  us  fairly  and  without  prejudice,  en- 
deavour to  ascertain  the  precise  state  of  the  arterial,  and  nervous 
systems,  at  this  time ;  and  from  this  examination,  see  whether  a 
stimulating  plan  of  treatment  is  fairly  deducible. 

410.  In  all  the  cases  we  have  witnessed  of  this  disease,  symp- 
toms, decidedly  marking  an  inflammatory  state  of  the  system, 
have,  to  a  greater  or  less  extent,  been  present,  for  a  shorter  or  a 
longer  period — that  is,  there  had  existed,  a  hot  dry  skin  ;  a  pulse 
full  and  hard;  head-ache,  of  more  or  less  severity;  high-coloured, 
or  very  pale,  crude  urine ;  a  white  slimy  tongue,  and  sometimes 
local  determinations,  manifested  by  acute  pain,  &c.  Now  if  these 
symptoms  do  not  betray  a  phlogosed  condition  of  some  one  of 
the  viscera,  we  should  be  at  a  loss  to  determine,  an  inflammatory 
state  of  the  system  under  any  circumstance,  and  if  they  do  not 
call  for  the  employment  of  the  lancet,  or  other  depletory  means, 
we  do  not  understand  in  any  case  whatever,  where  they  are  in- 
dicated. 

411.  But  should  these  means  be  neglected ;  inadequately  urged ; 
or  too  soon  withheld ;  we  shall  find,  a  change  in  several  of  the 
phenomena ;  but  none  in  the  general  character,  or  type  of  the 
fever.    There  will  as  certainly  be  present,  an  inflammatory  con- 
dition of  the  system,  as  there  was  before  the  change  took  place, 
either  by  neglect,  timidity,  or  improper  views.  And  though  the 
system  will  not  bear  depletion  to  the  extent  it  would  have  done 
before  the  vessels  had  in  part  destroyed  their  own  powers  by 
excessive  previous  action,  it  nevertheless  requires  it  to  an  ex- 
tent, that  must  be  regulated  by  the  apparent  force  of  the  symp- 
toms at  the  moment — at  all  events,  tonics  and  stimulants,  will 
be  destructive. 

412.  The  pulse,  and  the  local  determinations,  will  be  never- 
failing  guides  upon  such  occasions  to  the  attentive  observer; 
especially,  when  combined,  with  several  other  of  the  pheno- 
mena above  enumerated ;  as  the  flushed  face,  hot  skin,  delirium, 
&c.  &c. 

413.  The  pulse  in  such  cases,  will  constantly  declare  its  irri- 
tation ;  that  is,  it  will  be  both  quick,  and  frequent;  (see  par.  352,) 
with  a  marked  degree  of  incompressibility,  though  small  in  point 
of  volume ;  and  these  are  never-failing  marks,  that  the  system  is 
labouring  under  phlogosis,  in  some  one  part  or  other ;  and  from 
which,  it  cannot  be  relieved,  but  by  adequate,  and  well-directed 
evacuations. 

414.  Now,  the  great  error  in  practice  lies,  in  mistaking  this 
state  of  pulse,  for  a  pulse  of  debility  ;  because,  it  is  accompanied 
by  certain  changes  in  the  febrile  phenomena,  which  have  been 
too  constantly  and  wrongly  associated,  with  a  state  of  debility, 


134  CONTINUED    FEVER. 

and  which  it  is  supposed,  requires  for  its  removal,  tonics  and 
stimulants.  The  other  symptoms  accompanying  the  state  of  pulse 
just  described,  unfortunately,  from  mere  association,  lead  to  the 
same  conclusion.  Such  are  the  dry,  and  loaded,  or  the  dry,  and 
polished  ^ongue;  a  circumscribed  red,  or  hectical  cheek;  con- 
fusion of  intellect;  a  hot,  parched  skin,  and  more  or  less  of sub- 
sultus  tendinum.  We  would  now  ask,  is  there  any  thing  within 
the  range  of  pathological  research,  or  practical  observation,  that 
countenances  the  belief,  or  that  establishes  the  fact,  that  the 
symptoms  above  enumerated,  are  proofs  of  an  over-prevailing 
debility,  which  can  only  be  removed  by  tonics  and  stimulants? 

415.  We  hesitate  not,  to  say,  there  is  no  observations,  either 
pathological,  or  practical,  that  can  lead  to  such  conclusions.    On 
the  contrary,  we  can  with  the  utmost  confidence  declare,  that 
we  have  seen  all  these  symptoms  vanish,  by  general  or  topical 
bleeding;  by  purging;  by  a  strict  antiphlogistic  regimen;  by 
sponging  the  body ;  by  cold  local  applications,  and  by  sudorifics. 
And  further,  that  we  have  almost  invariably  seen  them  aggra- 
vated, by  the  tonic,  and  stimulating  modes  of  treatment.      "I 
have  seen,"  says  M.  D6chenaux,  "a  young  woman  getting  up 
in  a  few  days  from  her  lying-in  bed,  in  the  most  complete  ady- 
namic  state,  in  consequence  of  suckling  twins,  and  who  did  not 
take  nourishment  in  proportion.     But  her  tongue  was  pale  and 
moist,  and  the  system  without  febrile  movement.     With  a  view 
to  elevate  her  strength,  tonics  were  given  beyond  the  necessity 
of  the  case,  and  presently  her  tongue  became  dry,  rough,  and 
covered  with  a  brown  or  nearly  black  coat,  as  also  the  lips  and 
the  teeth — fever  now  declared  itself;  the  pulse  was  small  and 
frequent;  the  heat  acrid,  especially  upon  the  abdomen  ;  it  be- 
came distended  with  flatus ;  fetid  and  involuntary  stools.     The 
decoction  of  bark  which  she  had  for  her  common  drink  was  sus- 
pended ;  the  camphor  and  other  stimulants  were  replaced  by 
simple  lemonade,  and  broth."     And  Duges  says,  "  The  fourth 
period  of  fever,  (colaps,  asthenia,)  is  always  an  embarrassing 
state  of  the  system  to  the  physician,  as  frequently  the  mildest 
stimulants  excite  a  fatal  superaction;  fatal  by  the  exhaustion  it 
redoubles." 

416.  There  seems  to  be  a  species  of  infatuation  upon  the  sub- 
ject of  typhus,  that  is  no  less  surprising,  than  mischievous.  Sur- 
prising, because,  no  adequate  cause  can  be  assigned  for  it ;  and 
mischievous,  because,  it  leads  to  the  employment  of  remedies 
which  are  decidedly  destructive  of  human  life;  for  the  appre- 
hension of  an  event,  which  in  itself,  is  altogether  contingent, 
leads  to  a  practice,  that  seems  the  absolute  production,  of  this 
artificial  species  of  typhus.     Thus,  the  fear  of  debility,  and  its 
supposed  inseparable  attendant,  (typhus,)  are  attempted  to  be 


CONTINUED   FEVER.  135 

guarded  against,  by  the  administration  of  remedies,  altogether 
unsuited  to  the  nature  of  the  disease;  or  rather,Tto  the  condition 
of  the  system.  The  nervous  and  vascular  system,  have  now  to 
contend  with  the  force  of  the  remote  cause,  as  well  as  to  bear 
with  the  stimulation,  which  a  narrow  pathological  view,  has 
called  into  requisition. 

417.  The  disease  in  question,  has  an  anatomical  character 
without  doubt;  and  though,  we  do  not  consent  either  to  Brous- 
sais,  or  Clutterbuck's  exclusive  locations,  for  this  character,  (as 
both  are  certainly  right  at  times,)  yet  we  are  persuaded,  that  in 
every  instance  of  this  disease,  some  one  portion  of  the  system, 
has  been  acted  upon  in  an  especial  manner  by  the  remote 
cause;  which  will  have  the  effect  perhaps,  of  modifying  the 
force,  and  perhaps  the  succession  of  phenomena  attendant  upon 
the  disease  when  about  to  be  developed,  or  after  this  has  fully 
taken  place. 

418.  We  cannot  well  be  certain  that  there  is  not  a  phlogistic 
state  of  some  one  portion  of  the  system  ;  and  which  may  be  the 
cause  of  the  irritated  pulse,  and  the  other  symptoms  attendant 
upon  this  state  of  fever;  for  sometimes  we  have  no  other  evi- 
dence of  its  existence  than  the  pulse ;  as  there  may  be  no  local 
pain  to  detect  the  lurking  mischief.     In  this  situation  of  things, 
that  is,  of  local  inflammation,  stimulants  would  be  highly  inju- 
rious ;  for  they  would  with  the  utmost  certainty  increase  the 
evils  they  were  intended  to  remove. 

419.  It  is  therefore  always  safest  to  trust  to  the  mildest,  and 
most  temporising  plan  of  treatment ;  by  this  we  give  the  recu- 
perative powers  of  the  system  a  chance  of  doing  something  in 
favour  of  the  patient.    On  this  account  we  pay  attention,  first  to 
the  state  of  the  alimentary  canal ;  and  if  this  be  affected  by  loose, 
black,  fetid  stools,  we  give  mild  aperients  until  their  character 
change ;  for  it  is  in  vain  to  attempt  the  relief  of  the  system,  while 
these  stimulating  substances  occupy  the  intestines.    Second ;  we 
pay  a  great  regard  to  the  condition  of  the  skin ;  if  this  be  dry 
and  hot,  we  cause  it  to  be  sponged  with  cold  water,  and  give  the 
neutral  mixture,  or  the  sweet  spirit  of  nitre;*  if  partially  cold, 

*  There  are  few  articles  which  are  so  decidedly  refreshing  to  the  over-heat- 
ed system,  and  the  parched  mouth,  as  the  sweet  spirit  of  nitre;  it  may  be  given 
in  forty-drop  doses  in  a  little  sugar  and  water,  or  combined  in  a  smaller  pro- 
portion with  the  neutral  mixture,  or  Mindererus'  spirit,  (see  Art.  Spirit  of 
Mindererus. )  We  may  here  however  make  a  few  observations  upon  the  sweet 
spirit  of  nitre,  that  are  of  great  practical  import.  This  medicine  is  by  most 
practitioners  looked  upon  as  possessing  very  few  positive  powers,  or  active 
properties — it  has  therefore  been  most  negligently  prescribed,  and  has  in  con- 
sequence often  disappointed  expectation,  for  which  it  has  been  as  loudly  as 
unjustly  condemned.  This  discrepancy  has  arisen,  from  improper  doses  having 
been  given;  for  it  is  commonly  received  as  a  mere  placebo;  this  is  a  mistake. 
This  medicine  when  given  in  small  doses,  (that  is,  doses  not  exceeding  forty 


136  CONTINUED    FEVER. 

we  endeavour  to  establish  an  equality  of  temperature,  by  warm 
applications.  Third,  to  the  state  of  the  lower  extremities,  and 
the  degree  of  intellectual  sensibility.  If  the  legs  are  disposed  to 
become  cold ;  and  there  be  delirium  or  stupor,  we  apply  blisters 
to  the  calves  of  the  legs.  If  there  be  no  unusual  tendency  to 
coldness  in  the  limbs,  and  if  the  mind  be  much  affected,  we  have 
the  blister  applied  between  the  shoulders  and  down  the  spine. 
Fourth;  we  attentively  watch  for  the  appearance  of  local  inflam- 
mation, or  determinations.  The  existence  of  these,  are  some- 
times, it  must  be  confessed,  sufficiently  obscure,  if  no  other 
symptom  than  pain  is  to  be  regarded  as  evidence  of  them ;  but 
in  this  we  must  not  be  mislead;  since  pain  is  not  the  constant 
attendant  upon  these  conditions;  the  pulse  must  be  attentively 
examined.  It  will  be  well  to  bear  in  mind,  that  both  inflamma- 
tion, and  congestion  or  engorgement,  may  happen  at  any  period 
of  the  disease ;  and  when  extensive,  will  very  much  influence 
the  treatment.  For  though  inflammation  may  really  exist  during 
the  whole  progress  of  the  disease,  or  supervene  at  any  period  of 
it,  yet  its  character  will  in  great  measure  be  determined,  as  it 
may  be  initial,  or  secondary.  In  the  first  instance,  it  will  bear 
a  greater  loss  of  blood,  than  in  the  second  ;  and  the  loss  of  blood, 
either  directly  or  indirectly,  is  absolutely  necessary.  In  the  first 
case,  especially  in  the  early  part  of  it,  bleeding  from  the  arm. 
may  be  essential,  and  which  will  be  clearly  indicated  by  a  full, 
tense  pulse;  in  the  second,  leeching  or  cupping  the  part,  which 
is  the  seat  of  the  local  aberration,  will  be  all  that  may  be  required; 
Or  that  the  system  will  bear. 

420.  We  have  said  that  pain  does  not  always  betray  the  exact 
seat  of  the  inflammation,  or  engorgement;  this  is  strictly  true; 
but  the  spot  or  viscera,  may  be  known  with  considerable  accu- 
racy, by  certain  embarrassments  in  the  functions  of  such  viscera 
as  may  be  affected.  Thus  by  delirium,  we  may  declare  with 
almost  a  certainty,  that  the  seat  of  the  local  affection  is  in  the 
brain  or  its  appendages;  a  hurried,  very  slow,  or  a  laborious 
breathing,  may  detect  its  seat  in  the  lungs,  or  pleura;  by  a  sore- 
ness, fulness,  and  a  desire  to  lie  upon  the  right  side,  we  may 
have  a  just  suspicion  that  the  liver  is  its  location;  by  a  very 
scanty  supply  of  a  very  high-coloured  urine,  or  an  entire  sup- 
pression of  it,  we  may  declare  the  kidneys  to  be  involved. 

drops  once  in  two  hours  for  an  adult,  and  in  proportion  for  children,)  has  a 
most  tranquillizing  influence  upon  the  system  when  it  is  labouring  under  fever 
of  feeble  action,  and  dry  skin.  It  also  disposes  with  considerable  certainty  to 
the  surface;  especially,  when  combined  with  the  neutral  mixtures,  and  anti- 
mony. And  it  contributes  very  happily  to  diminish  the  unpleasant  after  effects 
of  laudanum;  we  have  known  patients  most  pleasantly  influenced  by  this  com- 
bination, that  would  have  suffered,  (if  they  could  trust  their  former  expe- 
rience,) very  much,  had  they  taken  the  laudanum  alone. 


CONTINUED    FEVER.  137 

421.  This  being  determined  with  as  much  certainty  as  the  na- 
ture of  the  case  will  permit;   the  proper  remedies  immediately 
present  themselves;  namely,  bleeding,  followed  in  many  instances 
by  blistering.     In  the  first  case,  blood  may  be  abstracted  from 
the  forehead,  by  leeching,  cupping,  or  by  the  division  of  the 
temporal  artery.     The  quantity  to  be  drawn  must  always  be  de- 
termined by  the  violence  of  the  symptoms,  and  the  state  of  the 
pulse.     In  the  second,  cupping  or  leeching  should  be  performed 
from  the  lower  part  of  the  neck,  and  from  between  the  upper 
portions  of  the  shoulder  blades.     In  the  third,  from  immediately 
over  the  region  of  the  liver,  and  by  the  same  means.     In  either 
of  these  cases,  the  loss  of  blood  may  be  followed  by  a  blister;  a, 
when  the  head  is  affected,  upon  the  neck  over  the  parts  pointed 
out  for  the  cupping  or  leeching;   b,  when  the  chest  is  affected, 
to  the  same  part;   c,  over  the  region  of  the  liver,  when  that 
organ  is  the  seat;  d,  by  leeching  or  cupping,  from  immediately 
over  the  kidneys.   (See  pars.  134,  135,  136,  &c.) 

422.  We  order  as  drinks  barley  water,  gum  Arabic  water, 
tamarind  water,  toast  water,  or  weak  lemonade,  to  be  given  cold; 
in  small  quantities;  but  to  be  frequently  repeated;  and  the  thin 
jellies  of  tapioca,  rice,  or  sago  sweetened,  and  rendered  pleasant 
by  lemon  juice,  to  be  given  from  time  to  time,  in  very  mode- 
rate quantities,  as  nourishment.     We  prohibit  in  the  strongest, 
and  most  unequivocal  language,  the  use  of  any  animal  juice,  or 
jelly,  in  any  shape  or  form  whatever;  as  well  as  every  stimulat- 
ing drink,  or  liquor,  either  fermented  or  distilled.     The  free 
ventilation  of  the  room,  by  the  constant  admission  of  fresh  air, 
is  an  indispensable  attention  in  this  form;  therefore  all  the  means 
and  cautions  suggested  in  page  36,  must  be  faithfully  attended 
to.  Also  changing  the  body,  and  bed-clothes,  as  often  as  circum- 
stances will  permit;  especially  if  the  weather  be  warm.     We 
must  never  listen  to  the  idle  prejudice  of  many,  that  "  chang- 
ing the  clothes  often,  is  weakening." 

423.  Let  us  now  inquire  into  the  state  of  the  nervous  system, 
in  this  fever.     In  doing  this  it  will  be  well  to  consider,  first, 
the  remote  or  morbid  agents;  second,  the  part  of  the  system  on 
which  they  exert  their  influence;  and  third,  the  phenomena  re- 
sulting from  their  application.     In  pursuing  these  inquiries,  it 
may  be  well  to  suggest,  that  the  nature  of  the  present  work  will 
only  permit  us  to  glance  at  each  of  these  subjects. 

424.  First.  The  remote  or  morbid  agents,  capable  of  causing 
fever,  may  be,  «,  marsh  miasmata;  of  these  effluvia,  we  know 
nothing;  either  chemically  or  physically.     They  have  eluded 
every  attempt  at  examination  hitherto  made;  nor  is  it  probable, 
that  either  chemical  tests,  or  analysis,  will  ever  instruct  us  in 
their  absolute  nature.     The  spots  from  whence  they  emanate, 

18 


138  CONTINUED    FEVER. 

are  well  known;  but  the  causes  necessary  or  accessary  to  their 
formation,  as  poisons,  are  at  present  altogether  inscrutable.  It 
is  true,  we  are  acquainted  with  certain  physical  agents  that  are 
essential  to  their  existence;  as  heat,  moisture,  and  vegetable  pro- 
ductions; but  more  is  required  than  these,  for  the  formation  of 
the  remote  cause  of  fevers;  as  we  see  these  three  agents  united 
frequently  without  the  production  of  malaria.  As  regards  the 
mere  physical  properties  of  the  air,  it  is  not  necessary  to  the 
production  of  malaria,  that  they  should  be  in  the  slightest  degree 
deteriorated,  if  we  can  place  any  reliance  upon  the  experiments 
performed  with  a  view  to  determine  this  point.  For  the  causes 
of  malaria  exist  without  the  possibility  of  detection  in  an  atmos- 
phere, that  offers  to  the  tests  of  the  philosopher,  proofs  of  the 
most  entire  salubrity.  We  therefore  shall  lose  nothing  by  con- 
fessing our  most  entire  ignorance  as  to  the  nature  of  such  miasms, 
as  are  capable  of  causing  fever;  with  their  effects  only  are  we  fa- 
miliar. 

425.  These  remote  agents  may  exist  however,  in  different 
degrees  of  concentration,  or  dilution;  and  on  these  degrees,  will 
the  nature  of  the  fever,  or  rather  will  the  different  phenomena 
and  type  of  fever  depend ;  making  at  the  same  time  allowance 
for  individual  susceptibilities. 

426.  b.  These  agents  may  be  a  product,  sui  generis  perhaps; 
arising  from  the  combination  of  bad  ventilation ;  effluvia  from 
human  bodies  when  too  closely  confined,  or  too  closely  crowded 
together ;  with  a  deficiency  of  wholesome  food  and  drinks. 

427.  c.  They  may  arise  from  a  diseased  body ;  and  thus  pro- 
pagate themselves  by  sending  forth  noxious  emanations,  which 
when  received  in  the  healthy  body,  are  capable  of  exciting  in  it 
the  same  kind  of  action,  by  which  they  themselves  were  pro- 
duced— that  is,  by  contagion. 

428.  Second.  The  part  of  the  system  on  which  these  morbific 
agents  act,  must  necessarily  be  the  nervous  system,  as  we  know 
of  no  other  that  gives  susceptibility.     Their  action  upon  this 
system  will  be  in  different  degrees,  as  the  poison  may  be  more 
or  less  concentrated,  as  the  dose  may  be  larger  or  smaller,  or  as 
the  susceptibility  may  be  more  or  less  exalted.     The  particular 
part  of  the  body  to  which  these  remote  causes  are  applied,  so  as 
to  act  upon  the  nervous  system,  is  not  so  settled  by  physicians 
as  to  be  beyond  the  power  of  controversy — the  greater  number 
of  pathologists,  however,  incline  to  fixing  the  seat  in  the  sto- 
mach. 

429.  Third.  If  the  remote  causes  be  susceptible  of  the  modi- 
fications above  named,  and  the  nervous  system  liable  to  the  dif- 
ferent degrees  of  susceptibility  just  spoken  of,  it  will  follow,  that 

the  influence  of  the  remote  cause  will  be  in  strict  obedience  to 


CONTINUED   FEVER.  139 

these  conditions;  and  hence  the  different  character  or  type  of 
fever.  It  will,  therefore,  happen,  that  a  certain  dose  of  the  poi- 
son, with  a  given  degree  of  nervous  susceptibility,  will  in  one 
instance  produce  fever,  the  character  of  which  shall  be  highly 
phlogistic;  another  as  strictly  inflammatory,  but  not  as  highly 
so;  another  with  still  less  of  the  inflammatory  type;  and  with  a 
fourth,  the  nervous  power  may  be  so  prostrated  by  the  strength, 
or  concentration,  or  peculiarity  of  the  poison,  or  the  remote 
cause,  that  no  febrile  reaction  will  take  place. 

430.  It  will  then  be  evident,  if  this  be  true,  that  all  fevers 
may  be  comprised  under  two  general  heads,  namely;  1st,  those 
in  which  there  is  a  greater  or  lesser  degree  of  inflammation ;  2d, 
those  in  which  inflammation  does  not  exist;  as  in  the  worst  forms 
of  pure  typhus.  (See  Sect,  on  Typhus. ) 

431.  The  first  effect  of  the  remote  cause  we  have  observed, 
is  upon  the  nervous  system  ;  to  which,  however,  it  is  but  a  short 
time  confined ;  for  such  is  the  nature  of  the  arrangement,  and  of 
the  mutual  relation  between  it  and  the  circulating  system,  that 
the  latter  is  soon  called  into  action ;  and  the  quality  of  this  sym- 
pathetic action  will  be  determined  altogether  perhaps  by  the  de- 
gree of  impression  made  upon  the  former.     So  intimate  and  in- 
separable are  the  relations  between  these  two  systems,  that  the 
one  cannot  be  acted  upon  with  any  force  by  the  remote  causes 
just  named,  without  exciting  the  other  to  inordinate  action,  or 
prostrating  it  below  the  power  of  action. 

432.  The  circulatory  system,  however,  is  evidently  dependent 
upon  the  nervous,  for  the  various  modifications  of  its  action ; 
while  on  the  other  hand,  the  nervous  system  is  reciprocally  de- 
pendent upon  the  circulatory. 

433.  Thus,  the  circulatory  system  could  not  have  its  action 
maintained  without  the  aid  of  the  nervous ;  nor  could  the  latter 
perform  its  functions  longer  than  the  former  continued  to  circu- 
late a  healthy  blood.     For  the  instant  that  venous  or  unoxyge- 
nated  blood  is  made  to  circulate  in  any  part  or  portion  of  the 
nervous  system,  that  instant  that  part  or  portion  has  its  actions 
to  abate  materially,  or  altogether  to  cease.     If  this  should  be  in 
the  brain,  or  the  medulla  oblongata,  respiration  would  be  very 
imperfectly  performed,  or  death  would  ensue,  from  this  process 
being  stopped.     If  there  be  only  a  small  deficiency  of  oxygen 
in  the  blood,  the  circulatory  system  will  feel  the  loss  of  this  ab- 
straction; but  the  change  will  be  less  marked.     If  the  blood  be 
more  than  ordinarily  charged  with  oxygen,  the  circulatory  sys- 
tem will  present  phenomena  that  mark  that  form  of  fever  called 
inflammatory ;  and  the  nervous  will  be  exalted  to  great  sensibi- 
lity, or  extreme  mobility. 

434.  It  will  therefore  follow,  from  what  has  been  said,  that 


140  CONTINUED    FEVER. 

the  character  of  febrile  phenomena  will  almost  exclusively  de- 
pend upon  the  impression  made  by  the  remote  cause  upon  the 
nervous  system,  be  the  nature  of  that  remote  cause  what  it  may — 
hence  the  variety  of  types  in  fever. 

435.  The   blood   itself,  while  circulating,  is  also  subject  to 
changes  in  its  structure,  if  we  may  so  term  it;  and  from  these 
changes,  some  of  which  are  made  evident  to  our  senses,  much 
is  inferred  in  the  treatment  of  diseases  of  the  febrile  kind.     To 
be  acquainted  with  the  more  evident  sensible  properties  of  the 
blood,  is  very  satisfactory,  but  not  always  so  important  as  is 
generally  imagined.  For  from  the  appearance  of  the  blood  alone, 
we  should  not  deduce,  either  the  necessity  for  its  further  abstrac- 
tion, or  for  our  withholding  the  lancet.   If  we  did  so  always,  we 
should  sometimes  abstain,  when  its  loss  would  be  all-important — 
for  instance,  when  it  is  in  the  condition  called  dissolved;  as  is 
the  case  sometimes  in  the  commencement  of  violent  onsets  of 
yellow  fever;  (see  par.  525,)  or,  we  should  continue  to  draw  it, 
when  each  loss  would  be  but  to  hasten  the  death  of  the  patient ; 
as  in  hectic  and  in  rheumatic  fevers;  for  here  we  have  seen  it 
cupped  or  sizy,  but  a  short  time  before  death. 

436.  Now  all  the  varied  appearances  of  the  blood  are  caused 
by  the  particular  actions  of  the  heart  and  arteries;  and  the  heart 
and  arteries  must  necessarily  depend  upon  the  state  of  the  nervous 
system,  for  their  peculiar  mode  of  action.   Changes  are  therefore 
effected  upon  the  whole  mass  of  circulating  fluids  in  the  course 
of  a  very  short  time.  And  these  changes  are  not  less  remarkable 
than  sudden  sometimes;  thus  death,  from  a  blow  upon  the  sto- 
mach, or  from  lightning,  are  said  to  prevent  the  coagulation  of 
the  blood. 

437.  From  this  view  of  the  subject,  the  nature  or  quality  of 
the  remote  cause  is  not  a  matter  of  indifference,  at  least  as  re- 
gards the  phenomena  and  type  of  fever.     Those  arising  from 
marsh  miasma,  in  otherwise  a  healthy  or  a  duly  oxygenated  at- 
mosphere, are  generally  fevers  of  the  sthenic  or  inflammatory 
kind,  provided  the  poison  be  not  too  much  concentrated,  or  the 
dose  too  large ;  for  the  mere  presence  of  oxygen  does  not  destroy 
the  cause  of  malaria.  But  the  absence  of  this  important  principle 
renders,  (perhaps  miasmata,)  but  certainly  the  combinations  of 
the  various  exhalations  arising  from  filth,  and  from  human  bo- 
dies in  crowded  places,  much  more  active  or  virulent. 

438.  Of  this,  however,  we  have  few  opportunities  to  witness, 
in  this  country,  though  some  of  our  public  institutions,   when 
unusually  crowded,  bear  testimony  to  the  truth  of  the  statements 
of  the  European  writers  upon  this  subject.   It  seems  to  be  agreed 
that  the  character  of  a  fever  generated  in  an  impure  atmosphere, 
will  be  quickly  altered,  by  a  change  to  a  more  pure  situation. 


CONTINUED   FEVER.  141 

By  this  change,  two  very  important  circumstances  take  place, 
both  of  which  doubtless  contribute  to  the  alteration  in  the  cha- 
racter of  the  fever  generated  in  the  impure  atmosphere — namely, 
a  due  and  healthy  supply  of  oxygen,  and  the  removal  from  the 
impurities  to  which  the  location  was  liable. 

439.  So  marked,  indeed,  is  the  influence  of  this  change  some- 
times, that  we  are  informed    by  Dr.  Burne,  that  "  patients  in 
whom,  in  their  own  habitations,  the  powers  of  life  were  very 
low,  and  indicating  cordials,  became  so  altered  after  the  removal, 
as  to  have  a  vigorous  circulation,  and  signs  of  inflammation, 
which  call  for  the  abstraction  of  blood."* 

440.  In  these  cases,  and  in  all  others  of  the  same  character, 
the  inflammatory  nature  of  the  disease  was  only  masked  by  the 
impression  made  upon  the  nervous  system  by  the  remote  cause 
or  causes;  giving  to  the  system  a  fallacious  appearance  of  pros- 
tration and  feebleness,  which  would  be  as  certainly  augmented 
by  stimulants,  as  it  would  be  diminished  by  well-proportioned 
•depletion.  How  depletion  acts  in  such  cases  to  remove  or  dimi- 
nish the  force  of  the  remote  causes,  our  limits  will  not  permit  us 
to  inquire.     All  that  is  necessary  to  understand  is,  that  it  is  a 
practical  truth,  or  else  all  the  latest  and  best  writers  upon  the 
subject  are  greatly  deceived.     And  this  similated  or  indirect 
weakness,  must  not  be  mistaken  for  an    absolute  exhaustion, 
and  supposed  to  require  for  its  removal,  cordial  and  stimulating 
remedies. 

441.  The  disposition  which  certain  continued  fevers  discover, 
sometimes  even  in  the  early  part  of  their  course,  to  take  on,  or 
similate  the  typhus  type,  has  too  frequently  led  to  the  most  de- 
structive practices  for  its  cure.     We  have  inculcated  this  belief 
-on  our  part,  again,  and  again;  in  the  hope,  that  those  who  may 
have  the  management  of  fevers,  may  at  least  pause,  before  they 
decide  against  a  plan  of  treatment,  opposite  to  their  usual  rou- 
tine, but  which  we  most  sincerely  think  has  both  reason  and  ex- 
perience on  its  side.     The  best,  and  latest  European  writers 
upon  the  subject  in  question  agree,  without  a  dissentient  voice, 
upon  the  following  general  principles. 

442.  First.   That  in  all  adynamic  fevers,  there  is  more  or 
less  inflammation  almost  constantly  present,  either  general,  or 
local. 

443.  Second.  That  even  during  this  more  or  less  inflamma- 
tory condition  of  the  system  in  general,  or  in  portions  of  it,  that 
the  most  unequivocal  evidence  exists,  that,  a  certain   combina- 
tion of  symptoms  will  present  themselves;  such  as  a  dry,  parched 

*  Burne  on  Typhus  or  Adynamic  Fever,  p.  43. 


142  CONTINUED    FEVER. 

tongue,  and  lips ;  flushed  cheeks;  low,  muttering  delirium;  a 
dry,  rough,  unrelenting  skin;  lying  upon  the  back,  with  the 
legs  drawn  up  ;  high-coloured,  scanty  urine;  subsultus  tendinum, 
picking  of  the  bed-clothes;  and  which  symptoms,  have  constantly, 
or  with  very  few  exceptions,  been  called  typhus,  or  typhoid 
symptoms. 

444.  Third.  That  the  symptoms  just  enumerated,  do  not  give 
evidence,  that  all  inflammation  is  at  an  end,  when  they  make 
their  appearance,  as  is  generally  supposed. 

445.  Fourth.  And  that  when  the  treatment  is  made  to  con- 
firm to  such  opinion,  by  the  employment  of  tonics,  and  stimu- 
lants, that  the  most  serious  consequences  have  followed  the  prac- 
tice. 

446.  Fifth.  That  though  the  symptoms  mark  a  less  active 
state  of  inflammatory  action,  yet  that  the  action  present,  never- 
theless is  of  the  phlogistic  kind ;  and  cannot  be  relieved  by  a 
stimulating  plan  of  treatment. 

447.  Sixth.  That  nothing   in  practice,  is  more  decidedly 
wrong,  or  more  actively  mischievous,  than  the  belief,  that,  when 
the  system  will  not  bear  active  depletion,  that  it  necessarily 
calls  for  the  opposite  mode  of  treatment. 

448.  Seventh.  That  it  is  now  agreeable  to  the  best  experience, 
that,  the  employment  of  stimulants,*  is  sure  to  be  followed  by  a 
marked  increase  of  every  bad  symptom;  and  that  when  reco- 
veries have  taken  place  under  the  stimulating  plan  of  cure,  they 
have  only  marked  the  strength  of  the  recuperative  powers  of  the 
system,  and  not  the  eligibility  of  the  plan  adopted. 

449.  Eighth.  That  when  the  system  is  in  that  forlorn  condi- 
tion, in  which  we  dare  not  deplete;  and  that  we  must  not  stimu- 
late, it  is  the  best,  and  most  successful  practice,  to  remove  all  the 
physical  causes  in  our  power,  that  may  have  a  tendency  to  de- 
press the  oppressed  system  ;  such  as  impure  air;  offensive  smells ; 
soiled  clothes ;  too  much  heat;  too  low  a  temperature;  too  great  a 
weight  of  bed-clothes;  and  too  much  company.     To  adminis- 
ter such  kind,  and  quantity  of  nourishment,  from  time  to  time, 
as  will  offer  the  least  trouble  to  the  feeble  digestive  powers; 
(such  as  has  already  been  specified  at  par.  217,)  and  such  drinks, 
as  will  make  an  agreeable  impresssion  upon  the  gustatory  nerves ; 
but  which  shall  not  convey  to  the  stomach,  any  decided  stimu- 
lating agency.     To  promote  to  the  last,  the  alvine  discharges  ; 

•  "  The  state  of  oppression  and  apparent  debility  induce  the  practitioner  too 
often  in  such  cases,  to  prescribe  a  tonic  plan  of  treatment;  but  it  should  be  re- 
membered, that  the  low,  depressed  condition  of  the  patient,  is  the  effect  of 
inflammation  in  the  brain,  or  its  membranes,  which  will  inevitably  be  increased 
by  the  administration  of  cordials."  Tweedie's  Illustrations,  p.  167. 


TYPHUS.  143 

either  by  injections,  or  by  the  mildest  aperients  ;*  to  effect,  (and 
if  necessary  by  even  artificial  means,)  the  flow  of  urine. 

SECT.  IV. — TYPHUS.! 

450.  The  disease,  strictly  called  typhus,  we  have  never  wit- 
nessed, though  we  have  strong  ground  to  believe,  that  it  has  oc- 
casionally appeared  in  the  alms-house  of  this  city.     The  disease 
bearing  this  name,  has  several  very  important,  and  remarkable 
peculiarities,  which  serve  to  distinguish  it  from  every  other  form 
of  fever ;  and  which  has  induced  Dr.  Bancroft  to  say — 

451.  "I  believe  in  the  existence  of  a  fever,  sui  generis, 
strictly  contagious,  (unconnected  with  any  of  the  exanthematous 
diseases,)  and,  therefore  according  to  my  view  of  the  subject, 
derived  exclusively  from  its  own  specific  cause,  or  contagion. 
In  this,  which  I  consider  as  the  only  contagious  fever,  there  are 
I  think,  some  varieties;  but  without  any  differences  sufficient  to 
form  more  than  one  species.  "J 

452.  The  opinions  of  Dr.  Bancroft,  upon  this  subject,  are  very 
valuable,  as  every  reliance  may  be  placed  upon  his  facts.    They 
are  for  the  most  part  derived  from  his  own  observations,  for 
which  he  had  frequent  opportunities,  as  well  as  large  sources  to 
collect  from;  we  shall  therefore,  cite  in  his  own  words  the  rea- 
sons for  the  opinions,  just  stated. 

453.  He  says,  p.  89,  et  seq.  ''Every  thing  which  I  have  been 
able  to  discover,  or  ascertain,  respecting  the  nature  and  proper- 
ties of  contagion,  induces  me  to  consider  each  of  its  several  spe- 
cies as  a  peculiar  morbid  quality  or  power,  imparted  to  certain 
animal  secretions,  in  consequence  of  some  particular,  though  un- 

*  In  the  last  stage  of  the  fever  under  consideration,  it  is  a  matter  of  great 
consequence  to  secure  a  regular  daily  discharge  from  the  bowels;  for  this  pur- 
pose we  have  proposed  the  mildest  aperients,  and  injections.     Of  the  former, 
the  simple  syrup  of  rhubarb  is  one  of  the  best — a  tea-spoonful  of  this  may  be 
given  once  in  an  hour  or  two,  until  the  effect  is  produced;  or  a  solution  of 
manna  in  the  drinks  of  the  patient,  will  often  be  sufficient.    The  injections  at 
this  period,  may  be  warm  molasses  and  water.   If  diarrhoea,  (but  not  if  it  be  of 
the  critical  kind,)  attend,  it  should  be  moderated  by  the  chalk  julep;  or  by 
small  doses  of  laudanum.  (See  Chalk  Julep.) 

f  "  Typhus  fever,  by  which  term  I  wish  to  denote  those  more  severe  forms, 
in  which,  from  the  commencement,  there  is  more  considerable  disturbance  in 
the  brain  and  nervous  system,  great  prostration  of  the  muscular  power,  with 
affection  of  the  mucous  membranes,  and  not  unfrequently  of  the  cutaneous 
and  glandular  systems.  We  find  this  form  of  fever  is  often  attended  also  with 
inflammatory  complications,  requiring  local  and  sometimes  even  general  abstrac- 
tion of  blood."  Illustrations  of  Fever.  By  A.  Tweedie,  M.  D.  p.  27.  It  would 
be  well  for  many  of  the  American  practitioners  to  attend  to  the  declaration 
marked  by  italics,  and  to  take  warning,  against  the  too  liberal  use  or  rather 
abuse  of  stimulants,  in  that  stage  of  fever  they  term  "typhus."  See  par.  400 
to  407. 

*  Bancroft  on  Yellow  Fever,  &c.  Davidge's  Ed.  p.  337. 


144  TYPHUS. 

known,  actions  excited  in  the  living  body,  when  actually  disor- 
dered, by  the  very  same  species  of  contagion  previously,  and  in 
like  manner,  elaborated  in  another  body  whilst  labouring  under 
a  similar  disorder  from  a  similar  cause ;  and  therefore,  though 
we  are  unacquainted  with  the  origin  of  any  one  species  of  conta- 
gion, yet,  considering  the  properties  manifested  by  all,  ever  since 
they  have  been  known  to  exist,  we  may  conclude,  that  being 
thus  produced,  exclusively  by,  and  within  the  living  body,  each 
is  capable  of  exciting,  in  other  bodies,  the  same  morbid  action, 
or  disease,  which  occasioned  its  own  production,  and  of  thus 
maintaining  and  propagating  itself,  indefinitely  ;  and  consequent- 
ly, that  though  contagion  be  a  morbid  and  morbific  secretion  or 
production,  it  is  also,  a  natural  one,  wholly,  inimitable,  either 
by  accident  or  art.  If  this  be  true,  it  must  follow  that,  though 
noxious  vapours  should  result  from  those  fortuitous,  and  ever- 
varying,  collections  of  unclean  or  putrifying  matters  commonly 
denominated  filth,  which  as  in  the  instance  of  marsh  effluvia, 
may  produce  diseases,  including  fever,  yet  the  diseases  so  pro- 
duced will  be  incapable  of  exciting  similar  diseases  in  other  per- 
sons, and  will  therefore  be  destitute  of  the  most  essential  property 
of  contagion." 

454.  From  these  facts,  the  following  important  conclusions 
may  be  drawn ;  first,  that  typhus  fever  is  a  contagious  fever;  that 
is,  it  is  capable  of  propagating  itself;  second,  that  it  is  the  only 
fever  that  possesses  this  quality,  if  the  exanthemata  be  excepted ; 
third,  that  the  contagion  or  poison  of  typhus,  is  sui  generis,  and 
bears  no  analogy  to  the  emanations  from  fevers,  which  have  con- 
fessedly other  causes,  than  the  contagion,  or  poison  of  typhus  for 
their  production;  fourth,  that  exhalations,  from  any  putrifying 
masses,  whether  animal  or  vegetable,  are  incapable  of  producing 
typhus. 

455.  We  learn  also  from  the  same  source,  that  typhus  is  very 
much  confined  to  Great  Britain ;  and  that  when  it  has  become 
prevalent  in  other  places,  it  was  constantly  introduced  into  such 
places  from  Great  Britain,  if  we  except  Holstein  and  Denmark, 
where  typhus  is  a  frequent  disease;  and  such  an  introduction 
took  place  in  the  year  1809,  by  the  Spanish  army  under  the 
Marquis  de  Romana. 

456.  Dr.  Bancroft  has  proved  beyond  all  controversy,  that 
neither  moisture  alone ;  putrifying  animal  or  vegetable  matter, 
nor  both ;  nor  crowding  the  sick  in  ill-aired  hospitals ;  or  the 
well,  in  a  confined  space,  as  the  black  hole  of  Calcutta,  has  ever 
in  a  single  instance  produced  typhus.   The  proofs  offered  by  this 
candid,  and  enlightened  writer,  are  so  numerous,  that  our  limits 
will  not  even  permit  an  analysis  of  them;  we  must  therefore  re- 
fer the  curious,  to  the  work  itself. 


TOPHUS.  145 

457.  We  have  already  in  several  places,  borne  testimony 
against  confounding  a  certain  condition  of  the  system,  in  the 
yellow,  the  continued,  and  the  remittent  fevers,  with  typhus ; 
because  they  bear  no  analogy  to  it;  as  they  all  want  the  power  of 
propagating  themselves,  by  contagion.  This  confusion  in  terms, 
has  necessarily  led  to  injurious  practice;  and  when  mischief  re- 
sults from  this  want  of  discrimination,  it  becomes  the  duty  of 
every  physician  to  oppose  such  an  amalgamation.    But  Dr.  Ban- 
croft does  not  stand  alone  in  what  he  has  advanced  on  the  subject 
of  typhus ;  he  is  supported  by  several  other  writers  of  eminence, 
and  especially,  by  Armstrong,  who  has  professedly  treated  of 
this  subject.     He  says,  "it  strikes  me,  that  to  call  any  species 
of  fever,  typhus,  which  has  not  the  contagious  essence,  capable 
of  producing  an  unequivocal  typhus,  is  equally  incorrect  in  logic 
as  in  language."     IpLtherefore  informs  us  in  his  valuable  essay 
upon  this  subject,  that  "the  word  typhus  shall  be  limited  to  the 
peculiar  disease,  which  is  allowed  to  originate  from  a  specific 
contagion,  and  which  doubtless,  has  the  power  of  producing  an 
affection  of  its  own  nature,  in  individuals  exposed  to  its  influ- 
ence." p.  7. 

458.  Dr.  Davidge  says,  "the  typhus  is  not,  so  far  as  my  ob- 
servations have  extended,  a  disease  of  Maryland,  perhaps  not  of 
America ;  at  any  rate,  not  south  of  the  New  England  states. 
And  since,  as  Armstrong  and  Bancroft,  and  most  other  enlight- 
ened physicians,  admit  contagion  as  essential  to  typhus,  (I  here 
refer  to  the  typhus  of  Britain  and  Ireland,)  it  must  be  highly 
absurd  to  speak  of  the  typhoid  condition  of  diseases,  in  regard 
to  those  diseases  that  are  not  admitted  to  be  contagious  in  any 
stage.     For  surely,  no  disease  can  be  said  to  be  like  another, 
that  is  deficient  in  an  essential  quality.     Hence,  it  appears,  how 
unphilosophic  the  language  is,  that  states  the  low  and  collapsed 
condition  of  the  body,  in  remittent  bilious  fever,  synocha  of  the 
winter,  or  pneumonia,  to  be  typhoid.  These  diseases  are  wholly 
distinct  from  typhus,  in  all  their  stages,  cause,  and  sensible  phe- 
nomena."* 

459.  Typhus  is  a  disease  of  cold  weather  exclusively;  and  its 
progress  is  as  certainly,  as  constantly  arrested  by  hot,  or  even 
by  warm  weather,  as  yellow  fever  is  by  cold  weather,  or  frost. 
This  is  a  remarkable  and  an  important  circumstance  in  the  his- 
tory of  this  disease ;  and  there  is  perhaps  no  one  fact  in  medical 
history  more  cordially  and  generally  acknowledged  by  all  writers 
upon  fevers.     Dr.  Bancroft  says,  that  "typhus  is  properly  a  dis- 
ease of  cold  climates."  p.  342.  •     ' 

460.  Dr.  John  Hunter  says,  "  I  have  never  seen  the  fever  ear- 

•  Davidge's  Edition  of  Bancroft,  p.  518. 
19 


146  TYPHUS. 

Her  than  the  month  of  November,  and  I  believe  it  seldom  appears 
so  soon.  It  becomes  frequent  about  Christmas,  and  increases 
during  the  months  of  January  and  February;  but  if  they  are  cold, 
it  continues  nearly  as  common  as  in  the  preceding  months."  He 
adds,  "  the  heat  proves  a  prevention  to  the  disease,  as  much  as 
cold  forwards  its  production."* 

461.  Drs.  Trotter,  Blane,  Lind,  &c.  all  confirm,  by  their  ob- 
servations, the  same  thing.    With  these  facts  before  us,  how  can 
typhus  be  talked  of  as  a  disease  of  warm  weather,  nay,  of  sum- 
mer! 

462.  Another  very  remarkable  circumstance  attends  the  his- 
tory of  typhus;  namely,  that  it  never  becomes  epidemic,  like 
fevers  arising  from  miasmata;  and  that  when  simple,  it  is  always 
of  the  continued  form.     Should  the  patient,  however,  have  been 
exposed  to  miasm,  it  may  cause  typhus  ift'assume  a  disposition 
to  remit,  but  not  without.     This  disease,  therefore,  must  not  be 
confounded  with  fevers  that  may  have  marsh  miasmata  for  their 
remote  causes;  nor  with  those  which  may  arise  "from  fatigue, 
damp  habitations,  unwholesome  or  insufficient  food,  anxiety, 
grief,  fear,  and  other  depressing  passions  and  debilitating  causes, 
which  have  no  connection  with  contagion,  nor  any  power  of 
producing  a  contagious  disease." 

463.  We  trust  we  have  said  enough  on  the  authority  of  those 
who  have  had  the  best  opportunities  to  observe  the  origin,  ha- 
bits, and  phenomena  of  typhus  to  prove,  that  it  is  not  a  disease 
of  the  American  climate,  or  but  very  partially  so;  and  that  when 
it  has  appeared  in  our  city,  if  it  ever  have  appeared,  it  has  always 
been  confined   to  our  poor-house.     Yet  \ve  hear  constantly  of 
typhus;  and  our  bills  of  mortality  never  fail  to  record  deaths 
from  this  fever.     We  have  already  confessed  we  have  never  had 
an  opportunity  of  seeing  a  single  case  of  this  disease;  nor  do  we 
believe  it  can  exist,  if  its  history  be  truly  given  by  the  highly 
respectable  gentleman  above  named,  in  our  more  southern  states. 

464.  It  certainly  never  prevails  within  the  tropics,  if  reliance 
can  be  placed  upon  the  writers  on  tropical  diseases.     Dr.  John 
Hunter  assures  us,  "that  during  more  than  two  years  that  he 
remained  in  Jamaica,  he  never  saw  one  instance  of  the  hospital 
fever,  though  the  military  hospitals  were  as  much  crowded  as  in 
Europe."  loc.  cit.     These  places  owe  their  exemption  from 
typhus,  to  the  heat  of  the  atmosphere ;  as  heat  and  typhus  toge- 
ther are  incompatibilities.   Dr.  Bancroft  says,  that  "the  influence 
of  heat  in  mitigating,  and  finally  extinguishing  contagious  fever, 
was  very  fully  manifested  in  regard  to  the  troops  which  sailed 
from  Cork,  under  the  command  of  JVIajor-General  White,  for 

•  Med.  Tntns.  Vol.  III.  p.  348,  &c. 


TYPHUS.  147 

St.  Domingo,,  in  February,  1796.  Two  hospital  ships,  in  which 
I  had  embarked,  and  sailed  from  England  with  the  army,  under 
Sir  Ralph  Abercrombie,  having  by  storms  been  rendered  unable 
to  continue  the  voyage,  and  the  last  of  them  having  landed  me 
on  the  south-west  coast  of  Ire,  I  embarked  on  board  a  very  large 
hospital  ship,  the  Bridgewater,  (formerly  an  Indiaman,) destined 
to  receive  the  sick  of  General  White's  division,  among  which  a 
severe  typhus  fever  had  prevailed  to  a  great  extent,  and  with 
great  mortality,  previous  to  our  sailing  from  Cork,  where  most 
of  the  sick  were  left  at  our  departure;  but  many  of  the  soldiers, 
apparently  well,  being  exposed  to  the  contagion  which  existed 
in  many  of  the  transports,  or  having  imbibed  it  previously,  while 
detained  at  Cork,  fell  sick  on  the  passage,  and  were  from  time  to 
time  removed  into  the  Bridgewater,  which  soon  became  full  of 
patients,  under  typhus  fever,  which  was  communicated  to  several 
of  the  orderly  men,  and  nurses,  to  some  of  which  it  proved  fatal. 
It  became  evident,  however,  that  as  we  reached,  and  proceeded 
in  the  warmer  latitudes,  the  cases  of  fever  gradually  diminished 
in  number,  and  became  much  milder;  though  from  the  shortness 
of  our  passage,  and  the  cool  season  in  which  it  was  made,  the 
full  effect  of  heat  in  extinguishing  contagious  fever  could  not 
have  been  produced ;  and,  therefore,  it  was  not  surprising  that  a 
few  patients  with  the  same  fever,  in  a  milder  form,  and  appa- 
rently divested  of  its  contagious  power,  were  sent  on  shore  to 
the  hospitals,  immediately  after  our  arrival  at  Barbadoes.  These 
had  probably  imbibed  the  contagion  before  our  arrival  within 
the  tropics,  and  its  effects,  though  moderated,  were  not  wholly 
prevented  by  a  change  of  temperature."  p.  343. 

465.  Similar  facts  could  be  easily  added,  were  it  necessary, 
or  compatible  with  our  plan — enough  has  been  shown  to  prove, 
that  typhus  fever  has  its  own  peculiar  laws,  and  phenomena; 
but  none  of  which  belong  to  any  of  the  fevers  of  our  seasons; 
consequently,  none  of  such  fevers  can  be  typhus. 

466.  As  we  have  never  had  an  opportunity  of  seeing  a  case 
of  typhus,  as  we  have  already  declared,  we  shall  be  indebted  to 
others  for  a  description  of  this  fever.     The  latest,  and  perhaps 
the  most  approved  account  we  have  of  typhus  as  it  exists,  in 
Great  Britain  in  general,  and  London  in  particular,  is  that  of 
Dr.  Burne,  in  his  Treatise  on  the  Typhus  or  Adynamic  Fever. 

467.  He  says  there  are  two  modes  of  attack.   "  The  adynamic 
fever  frequently  attacks  young  persons  in  the  vigour  of  youth, 
between  the  age  of  eighteen  and  twenty-five,  having  robust  con- 
stitutions, and  who  had  enjoyed  good  health  up  to  the  invasion 
of  the  disease.     These  peculiarities  are  remarkable.     In  order 
to  the  production  of  the  adynamic  fever,  it  is  necessary   that 
there  be  a  certain  state  of  system;  which  state  depends,  in  most 


148  TYPHUS. 

instances,  on  a  continued  exposure  to  a  poisoned,  or  contamU 
nated  atmosphere.  This  state  then  existing,  it  will  be  found 
that  the  adynamic  fever  attacks  in  two  ways ;  and  it  is  of  great 
importance  that  these  should  be  clearly  understood,  because  they 
account  for  the  presence,  or  supervention  of  inflammation  in 
some  cases,  and  the  absence  of  it  in  others."  p.  13. 

468.  "  In  one  instance  it  acts  by  the  intervention  of  an  acci- 
dental cause;  the  other  without.  When  without  the  intervention 
of  an  accidental  cause,  the  condition  of  the  body  itself  is  suffi- 
cient to  give  rise  to  the  phenomena  of  adynamic  fever.     When 
with  an  accidental  cause,  the  condition  of  the  body,  though  not 
sufficient  of  itself  to  produce  the  fever,  is  yet  sufficient  to  give 
the  fever  thus  accidentally  produced,  the  peculiar  adynamic  type. 
In  the  one  case,  the  development  is  slow  and  progressive,  re- 
quiring many  days,  or  even  weeks;  in  the  other,  it  is  fully  form- 
ed in  a  few  hours."  p.  14. 

"  Of  the  Way  of  Attack  without  an  Accidental  Cause." 

469.  The  signs  of  this  mode,  are  disinclination  of  food,  lassi- 
tude, weakness;  to  these  are  added  slight  head-ache,  and  chilli- 
ness.    In  a  day  or  two  these  symptoms  increase ;  together  with 
pain  in   the  back  and  limbs ;  shivering,  followed  by  heat  and 
sweating;  "so  that  a  febrile  paroxysm  is  established."  p.  15. 
These  recur  daily ;  especially  about  noon.  Others  experience  the 
exacerbation  in  the  evening ;  others  again,  will  be  laid  up  from 
the  very  invasion — in  these  the  symptoms  run  high.  While  some 
will  complain  for  several  days,  and  'then  be  attacked  suddenly; 
and  this  frequently  after  a  meal.     This  attack  is  not  commonly 
attended  "  by  any  organic  inflammation."  p.  17. 

"  Of  the  Way  of  Attack  with  an  Accidental  Cause." 

470.  "  That  cause  is  generally  a  severe  cold,  from  exposure 
to  rain,  wind,  &c."  The  initial  symptoms  much  the  same,  only 
perhaps  more  pronounced,  and  the  chilliness,  &c.  will  continue 
for  two,  three,  or  more  hours;  "  when  a  violent  reaction  takes 
place,  and  the  skin  becomes  hot  and  dry,  the  face  suffused,  with 
an  increase  of  action  of  the  heart  and  arteries."     "  When  this 
fever  attacks  in  this  way,  organic  inflammations  are  apt  to  ac- 
company it  from  the  beginning."  p.  18. 

471.  "  The  adynamic  fever  being  produced  in  one  of  the  two 
ways  just  described,  it  will  be  found  to  differ  very  much  in  se- 
verity: for  which  reason,  and  for  practical  purposes,  it  is  expe- 
dient to  divide  it  into  degrees;  and  these  may  with  great  pro- 
priety be  limited  to  four."  p.  19. 


TYPHUS.  149 


"  Of  the,  First  Degree." 

472.  This  is  mild ;  merely  slight  head-ache;  sometimes  none; 
some  reaction.     Appetite  poor;  tongue  covered  with  a  dirty 
white  covering,  except  the  end,  which  is  red,  with  prominent 
papillae  and  moist.     Cheeks  flushed,  eyes  rather  suffused ;  senses 
dull;  great  prostration  for  the  existing  symptoms.   Urine  scanty 
and  high-coloured ;  bowels  sluggish ;  seldom  delirium  ;  refreshing 
sleep  during  the  night,  p.  19. 

"  Of  the  Second  Degree." 

473.  Considerable  head-ache ;  sight  and  hearing  less  acute; 
noise  and  light  unpleasant.     Suffusion  and  fulness  of  face;  bluish 
blush  on   the  cheek.     Considerable   reaction;   pulse  frequent, 
rather  full  and  strong,  but  compressible  by  moderate  force; 
pulse  deceptive;  is  open  from  want  of  tonicity,  and   may  be 
mistaken  for  great  fulness.     Tongue  the  same,  except  that  the 
coating  is  thicker  and  more  dirty.     Skin  hot  and  somewhat 
tight;  dusky  suffusion  on  the  skin.     Bowels  disposed  to  consti- 
pation ;    belly   distended.     Urine    high-coloured,   and    scanty ; 
strength  greatly  prostrated.   The  patient  on  the  side  sometimes, 
and  sometimes  on  the  back.     During  the  day  drowsy;  during 
the  night  delirious,  p.  20. 

"  Of  the  Third  Degree." 

474.  Third  degree  severe;  great  prostration;  patient  lies  on 
his  back;  breathes  slowly  and  deeply,  as  one  in  a  lethargic  sleep. 
Unable  to  turn,  and  averse  from  motion.     Can  speak  only  in 
broken  sentences.  Tremors  and  twitchings  of  the  muscles.  Can- 
not stand  if  taken  out  of  bed.     Dullness  and  torpor  of  all  the 
senses;  obliged  to  repeat  questions  before  an  answer  is  obtained; 
complains  of  a  dull  pain  in  the  head;  great  thirst 

475.  Face  void  of  expression  ;*  every  feature  relaxed ;  skin 
dusky;  purplish,  circumscribed  flush  on  the  cheek;  eyes  suffused 
and  glassy,  with  shreds  of  mucous  matter  floating  in  them.  Lips 
blue;  teeth  dry  and  shining;  viscid  mucus  in  the  corners  of  the 
mouth,  which  is  drawn  into  filaments  when  the  tongue  is  pro- 
truded; this  mucus  dries,  and  covers  the  teeth  and  lips  with 

*  "  Many  of  the  characters  of  typhoid  fever  are  unsusceptible  of  accurate 
description;  and  of  these  the  most  remarkable  is  the  expression  of  countenance, 
so  uniform  as  to  make  all  typhoid  patients,  in  a  great  degree,  resemble  each 
other." — Gregory's  Elements  of  the  Theory  and  Practice  of  Physic,  3d  Am. 
Ed.  p.  66. 


150  TYPHUS. 

blackish  sordes.  Breath  peculiarly  offensive.  Tongue  thickly 
coated;  brown  and  dry  in  the  middle;  red  and  dry  at  the  tip; 
whitish  and  moist  at  the  sides.  The  pulse  seldom  exceeding 
90;  sometimes  not  above  the  natural  standard;  fullish,  sometimes 
rather  firm,  but  always  more  or  less  compressible.  The  skin  dry 
and  rather  harsh;  temperature  variable;  at  one  moment  high,  at 
another  not  much  increased.  Urine  always  scanty  and  high-co- 
loured, and  becomes  turbid  on  standing.  Belly  full;  tender  on 
heavy  pressure.  Bowels  generally  sluggish;  sometimes  relaxed; 
dejections  dark  and  offensive;  restlessness;  constant  delirium 
through  the  night;  frequent  attempts  to  get  out  of  bed ;  delirium 
sometimes  in  the  day. 

476.  These  symptoms  change  in  a  few  days,  for  the  better  or 
worse.     If  for  the  better,   prostration,  lethargy,  and  dullness, 
diminished ;  patient  turns  upon  his  side;  less  viscidity  about  the 
mouth;  tongue  moistens,  and  commences  cleaning;  spontaneous 
diarrhoea  of  ochre-coloured  stools;  pulse  natural;  skin  soft  and 
moist;  eyes  brighten;  skin  clean;  countenance  more  animated; 
delirium  ceases;  sleep  refreshing;  convalescence.     If  an  unfa- 
vourable change  takes  place ;  there  will  be  constant  delirium ; 
great  jactitation ;  violent  and   frequent  screaming,  which   only 
subsides  with  the  powers  of  life — drowsiness  increases;  skin 
becomes  purple;  temperature  sinks;  extremities  cold — death. 
p.  21,  &c. 

"  Of  the  Fourth  Degree." 

477.  Soon  as  fever  begins,  the  symptoms  become  grave.    Pa- 
tient lies  upon  his  back,  in  nervous  agitation,  picking  the  bed- 
clothes ;  countenance  haggard,  and  visage  sharp ;  carotids  vibrate; 
respiration  quick;  breath  strong  with  the  odour  peculiar  to  this 
fever.     The  eyes  suffused  and  sometimes  convulsed,  moving 
from  side  to  side ;  eyelids  depend,  and  there  is  a  ghastly  stare. 
Mouth  parched  ;  sooty  coating  on  tongue,  dry,  hard ;  lips  and 
teeth  covered  with  black  sordes.     Skin  hot,  dry,  harsh  ;  fre- 
quently spotted  with  petechiae.     The  pulse  from   100,  to  120  ; 
stroke  unsteady,  open ;  very  compressible.     Bowels  relaxed ; 
belly  tender  on  pressure,  and  full ;  stools  black  and  highly  offen- 
sive, and  passed  with  the  urine  involuntarily.     Voice  husky  ; 
articulation  muttering;  emaciation  rapid. 

478.  Under  these  circumstances  the  disease  frequently  runs  a 
rapid  and  fatal  course.     If  the  patient  survive,  recovery  is  slow. 
A  favourable  change  is  announced  by  the  countenance  improv- 
ing; abatement  of  the  violence  of  all  the  symptoms;  and  by  a 
return  of  sleep  and  consciousness.     Secretions  return ;  tongue 
clears;  ochre-coloured  frothy  stools.  Urine  more  abundant;  de- 


TYPHUS.  151 

posites  a  lateritious  or  brick-dust  coloured  sediment.    Pulse  less 
frequent,  and  gradually  convalescence. 

479.  "  When  the  secretions  are  re-established,  and  the  tongue 
has  cast  oft' its  fuliginous  coat,  the  lips  and  tongue  are  left  red, 
tender,  and  sore,  and  as  it  were  raw.     And  this  condition  ex- 
tends throughout  the  mucous  lining  of  the  intestinal  canal,  caus- 
ing great  soreness  of  the  belly,  keeping  up  the  diarrhoea,  and 
rendering  the  stomach  and  bowels  highly  sensible  to  the  opera- 
tion of  medicines,  or  the  presence  of  undigested  food ;  which 
makes  it  important  to  pay  strict  attention  to  this  condition  in 
the  treatment  of  persons  recovering  from  the  adynamic  fever." 
p.  26. 

480.  When  it  terminates  fatally,  all  the  symptoms  are  aggra- 
vated, strength  diminishes;  the  patient  continues  supine,  and 
motionless ;  the  arms  stretched  out,  or  cross  the  chest ;  visage 
sharper;  face  sweaty  and  cadaverous;  eyes  fixed  ;  eyelids  nearly 
closed;  belly   tympanitic,  temperature  diminished,  extremities 
cold ;  pulse  rapid,  small,  and  weak,  faultering;  life  gradually  ex- 
tinguished, p.  27. 

"  Treatment  of  the  First  Degree" 

481.  "The  character  of  this  degree  of  the  adynamic  fever  is 
so  mild  as  to  require  very  little  medical  aid." 

482.  "  It  is  only  necessary  to  supply  the  patient  with  good 
air  and  fresh  linen  ;  to  keep  the  bowels  rather  freely  open  by  any 
aperients ;  (as  castor  oil,  rhubarb,  magnesia,  and  senna  and  man- 
na, but  Dr.  B.  prefers  rhubarb,)  and  to  give  a  simple  saline,  as 
the  liq.  ammon.  acet.  in  the  dose  of  three  drachms  three  times 
a  day." 

483.  "  No  other  food  than  gruel  to  be  allowed  till  the  head- 
ache and  flushing  of  the  face  have  subsided,    and  the  tongue 
has  become  clean ;  when  a  nutritious  diet  may  be  gradually  re" 
sumed."*  p.  206. 

"  Of  the  treatment  of  the  Second  Degree." 

484.  "The  object  is  to  moderate  the  symptoms,  and  to  pro- 
tect the  various  organs  against  an  undue  momentum  of  blood, 
which  may  lead  to  inflammation  in  any  organ  so  disposed." 

4S5.  "This  end  will  be  effected  by  the  abstraction  of  six  or 
eight  ounces  of  blood  from  a  vein,  which  may  be  repeated  in 
forty-eight  hours,  if  the  first  bleeding  has  been  beneficial,  and 

•  It  may  be  useful  to  solicit  the  attention  of  the  reader,  to  this  mild  mode  of 
treating  typhus — here  no  stimulants  are  prescribed — no  wine  whey;  no  barkj 
no  volatile  alkali,  are  ordered. 


152  TYPHUS. 

circumstances  call  for  a  second  ;  but  if  the  general  febrile  excite- 
ment has  been  moderate,  and  the  head-ache  is  still  severe,  two 
or  three  ounces  may  be  taken  from, behind  the  ear,  with  the  cup- 
ping-glass, with  great  advantage." 

486.  "The  bowels  are  sluggish,  and  the  belly   often   flatu- 
lent; which  must  be  counteracted  by  aperients  given  every  or 
every  second  clay,  so  as  to  keep  them  freely  open;  and  the  more 
dark  and  offensive  the  dejections,  the  more  are  aperients  to  be 
persevered  in." 

487.  Calomel  in  two  grain  doses  with  six  or  eight  of  rhubarb 
may  also  be  given  as  an  aperient,  "  but  as  the  belly  is  flatulent, 
which  shows  a  disposition  to  the  irritation  and  organic  affection 
of  the  intestinal  canal  peculiar  to  this  disease,  it  is  prudent  to  use 
mercury  sparingly,  and  towards  the  decline  of  the  disease,  dis- 
continue its  use  altogether."  p.  208. 

488.  A  three  drachm  dose  of  the  liq.  ammon.    acet.  should 
also  be  given  every  four  hours.   The  night  delirium  requires  no 
particular  treatment.  The  hair  should  be  cut  close ;  and  the  head 
frequently  sponged,   p.  209. 

"  Of  the,  treatment  of  the  Third  Degree" 

489.  Blood  is  not  to  be  taken  from  the  arm ;  but  much  relief 
is  afforded  by  taking  three  or  four  ounces  from  behind  the  ear,  by 
cupping,  and  this  may  be  repeated,  in  a  day  or  two  if  the  stupor 
continue.     A  blister  of  not  a  large  size  should  be  applied  to  the 
crown  of  the  head,  in  preference  to  between    the    shoulders. 
p.  211. 

490.  "  It  is  in  this  degree  of  adynamic  fever  that  the  external 
use  of  mercury  is  so  eminently  serviceable;  because  of  its  un- 
rivalled power  to  bring  about,  speedily,  a  re-establishment  of  the 
secretions;  the  mercury  is  to  be  rubbed  in  on  any  convenient 
surface  of  the  body;  as  the  inside  of  the  thigh,  in  the  quantity 
of  about  half  a  drachm  of  the  ung.  hydrarg.  fort,  every  night  and 
morning,  till  it  effects  the  desired  purpose."  p.  211. 

491.  The  bowels  are  to  be  daily  moved  by  aperients,  though 
the  bowels  be  relaxed,  and  continued  until  as  long  as  the  stools 
are  dark  and  offensive — rhubarb  is  particularly  appropriate  in  six 
or  eight  grain  doses.     After  the  bowels  have  been  well  opened, 
and  blood  abstracted,  a  grain  of  opium,  or  hyosciamus  may  be 
given  if  the  delirium  and  restlessness  continue. 

492.  If  the  ochre-coloured  diarrhoea  supervene,  it  must  be 
treated  by  "  demulcent  drinks,  as  barley  water,  rice  water,  gum 
water,  and  the  like" — "  as  regards  the  diarrhoea  no  other  treat- 
ment is  called  for,  unless  it  be  protracted  and  evidently  affects 
the  patient's  strength;  in  which  case  the  irritation  of  the  bowels 


TYPHUS.  153 

must  be  allayed  by  small  and  repeated  doses  of  opium,  as  three 
drops  of  the  tinct.  opii." 

493.  "  Sometimes  at  the  commencement  of  this  diarrhoea,  the 
belly  will  continue  flatulent  and  the  dejections    offensive ;    in 
which  case  the  tongue,  though  nearly  clean,  will  be  dry  and  of  a 
light-brown,  and  the  cheeks  will  be  flushed."  p.  234. 

494.  Aperients  must  here  be  used;  but  they  must  be  given 
in  very  small  doses.   Rhubarb  is  to  be  preferred ;  and  five  grains 
is  a  sufficient  dose,  and  repeated  every  six  hours,  until  the  de- 
jections lose  their  offensive  smell,  and  the  tongue  becomes  clean, 
p.  235. 

"  Treatment  of  the  Fourth  Degree" 

495.  "  The  treatment  should  be  directed  particularly  to  the 
intestinal  canal,  as  the  nervous  excitement  and  debility  are  kept 
up  and  augmented  by  any  loiteringor  lodgment  of  the  black  offen- 
sive faeces.  Rhubarb,  is  unquestionably  the  best  aperient."  Eight 
or  ten  grains  of  rhubarb  with  as  much  of  the  confect.  opii.  and 
one   drachm  of  syr.   zinzeb.  in  cinnamon  water;*  and  be  re- 
peated every  four  or  six  hours  until  the  bowels  are  satisfactorily 
emptied.     Castor  oil  if  preferred  may  be  given  in  two  or  three 
drachm  doses  in  a  glass  of  Sherry  wine.   The  hair  to  be  clipped; 
the  head  sponged  with  cold  water ;  and  tepid  or  warm  ablution 
of  any  part  of  the  body  where  the  skin  is  dry  and  harsh  is  very 
refreshing,   p.  215. 

496.  "  Mercury,  a?  before  advised,  should  be  had  recourse  to, 
a  saline  effervescing  draught  of  half  its  usual  strength ;  as  ten 
grains  of  the  carbonate  of  potassa  with  two  drachms  of  fresh 
lemon  juice.     As  soon  as  the  bowels  are  well  cleansed,  opium 
may  be  given  as  just  directed,  also  a  decoction  of  the  bark,  in 
the  dose  of  one  ounce  and  a  half  ;t  or  the  sulphate  of  quinine,  in 
the  dose  of  one  grain,  with  one  minim  of  the  diluted  sulphuric 
acid,  and  a  drachm  of  the  tincture  of  orange  peel.  The  bark  and 
effervescing  mixture^  to  be  given  alternately,  p.  216. 

497.  "If  the  prostration  be  very  great,  and  the  bowels  re- 

*  Take  of  Rhubarb,    -        -        -        -        8  or  10  grains. 
Confection  of  opium,  10  grains. 

Syrup  of  ginger,          -        -        1  drachm. 
Cinnamon  water,      '    •     .  -        Enough  to  make  into  a  draught. 

Mix  together, 
f  Decoction  of  bark. 

Take  one  ounce  of  bark  in  powder. 
One  pint  of  water. 

Mix,  and  let  them  simmer  slowly  for  twenty  minutes;  permit  it  to  settle,  and 
give  a  wine-glassful  every  two  hours. 

$  For  effervescing  mixture,  see  Appendix,  Art.  Effervescing  Mixture. 

20 


154  YELLOW    FEVER. 

lieved,  it  must  be  supported  by  porter,  or  brandy  and  water ; 
beginning  with  them  very  sparingly,  and  increasing  according 
to  necessity,  p.  216." 

498.  We  have  thus  given  the  general  outline  of  Dr.  Burne's 
account  and  treatment  of  typhus  fever ;  it  will  be  quickly  per- 
ceived, that  his  plan  is  very  different  from  that,  which  is  gene- 
rally pursued  in  this  country  by  many  practitioners  for  this  sup- 
posed disease  as  supervening  upon  our  miasmatic  fevers,  and  as 
we  have  had  occasion  to  remark  at  p.  130  et  seq.     With  those 
who  dread  the  onset  of  typhus  in  every  species  of  fever ;  this 
practice  will  not  be  altogether  approved  of — "  what,"  say  they, 
"bleed,  cup,  and  purge,  when  typhus  is  impending!!     No,  no, 
give  bark,  wine,  volatile  alkali,  brandy,  ether,  phosphorus,  &c. 

&c.  if  you  mean  to  cure  the  disease." 

) 

SECT.  V. — YELLOW  FEVER. 

499.  By  yellow  fever  we  mean  a  disease  of  specific  character, 
one  that  differs  from  the  endemic  remittents  of  tropical  climates, 
and  from  those  of  the  southern  portions  of  our  continent.     This 
disease,  by  some,  has  been  considered  as  only  an  exalted  form  of 
the  bilious  remittent;  but  there  are  peculiarities  in  its  history 
that  show  it  to  be  a  distinct  disease.   We  shall  therefore  enume- 
rate the  several  remarkable  circumstances  connected  with  it, 
which  have  led  us  to  adopt  the  opinion  of  Jackson  and  some 
others  on  this  subject,  and  which  in  our  opinion  are  conclusive. 

500.  1.  It  has  been  remarked  by  many  of  the  physicians  and 
inhabitants  of  the  West  Indies,  that  the  negroes  immediately 
from  the  coast  of  Africa  were  never  attacked  with  this  disease, 
and  the  native  West  Indian,  or  Creole,  is  likewise  exempt  from 
it,  provided  he  uninterruptedly  remain  in  the  place  of  his  nati- 
vity; but  should  he  or  the  negro  pass  a  year  or  two  in  Europe, 
or  in  the  higher  latitudes  of  America,  they  would  be  liable  to 
this  complaint. 

501.  2.  Strangers  are  particularly  liable  to  this  disease  on  their 
arrival  in  the  West  Indies,  or  on  certain  portions  of  our  conti- 
nent. But  should  they  escape  it  for  the  first  or  second  year,  they 
will  most  probably  be  exempt  from  its  attack;  and  more  certainly, 
if  they  had  suffered  from  the  endemical  fever  of  these  climates. 
This  is  what  is  familiarly  termed  "the  seasoning." 

502.  3.  It  has  been  very  rarely  found  to  attack  the  same  per- 
son a  second  time,  while  the  endemial  fever  may  be  repeated 
several  times. 

503.  Some  of  these  facts  are  well  established,  and  seem  de- 
cidedly to  mark  a  difference  between  the  bilious  remittent  and 
yellow  fever..    Nor  are  we  entirely  indebted  to  the  writers  on 


YELLOW    FEVEB.  155 

tropical  diseases  for  these  marked  peculiarities  of  the  yellow 
fever;  for  the  same  has  been  observed,  and  recorded  in  part,  if 
not  entirely,  in  our  own  country. 

504.  The  first  visit  this  formidable  disease  paid  us,  which  is 
still  fresh  in  our  memories,  was  in  1793;  and  it  was  then  fre- 
quently observed,  that  the  Creole  population,  which  was  at  that 
time  considerable,  was  almost  entirely  exempt  from  its  attacks;* 
and  more  especially  the  coloured  part  of  it.    It  must  be  remark- 
fid  that  there  was  at  this  period  a  large  influx  of  West  India  in- 
habitants into  our  city,  and  chiefly  French.     But  after  they  had 
remained  here  a  few  years,  they  seemed  to  lose  in  a  degree  their 
immunity  from  attack;  accordingly,  instances  of  this  disease  oc- 
curred among  them,  as  well  as  among  the  native  inhabitants. 

505.  It  was  also  remarked  at  this  and  at  subsequent  periods, 
that  the  transient  visitors  from  the  surrounding  country,  were 
more  obnoxious  to  this  disease  than  those  who  permanently  re- 
sided in  this  city,  provided  they  visited  certain  portions  of  the 
town.     And  if  we  can  trust  to  observation,  the  fact  of  a  person 
"not  being  liable  to  a  second  attack/'  was  confirmed  by  the 
subsequent  visitation  of  this  terrible  scourge,  and  which  we 
think  put  the  circumstance  to  as  fair  an  issue  as  negative  proof 
could  do. 

506.  From  these  considerations,  we  think  we  are  warranted 
in  the  conclusion,  that  "the  yellow  fever,  and  an  exalted  form 
of  bilious  remittent,  are  not  one  and  the  same  disease."     How 
far  a  distinction  between  them  may  lead  to  any  practical  utility, 
we  are  not  at  present  prepared  to  say;  but  that  it  may  at  some 
future  time,  we  do  not  hesitate  to  believe.     At  present  we  treat 
the  two  diseases  pretty  much  after  the  same  manner;  differing 
more  in  the  rigour  of  application  than  in  the  routine  and  nature 
of  the  agents  employed. 

507.  This  disease  attacks  variously;  insidiously j  openly,  or 
ferociously.     In  this  particular  it  differs  .perhaps  from  almost 
every  other  febrile  disease — for  in  these,  the  danger  is  generally 
in  proportion  to  the  intensity  of  the  symptoms;  but  yellow  fever 
when  masked  under  an  apparently  mild  form,  is  dangerous  in 
the  extreme.     In  general  we  have  remarked  more  instances  of 
recovery  where  the  disease  assumed  an  open,  severe,  but  tangi- 
ble form,  than  where  neither  the  pulse  nor  other  symptoms  be- 
trayed the  ravages  the  disease  was  making.     In  some  cases  the 
whole  system  appeared  to  be  prostrated  beyond  the  power  of  re- 

•  We  say  "  almost  entirely  exempt  from  its  attacks."  We  choose  to  employ 
this  cautious  language,  because  we  could  not  say  there  was  no  such  exception 
to*he  rule;  but  we  can  very  confidently  declare  that  we  did  not  hear  of  an 
exception;  for  at  this  period,  they  had  been  but  a  very  short  time  from  St. 
Domingo. 


156  YELLOW    FEVER. 

action  ;  and  death  was  frequently  at  hand,  when  the  patient  was 
perhaps  walking  the  floor,  or  but  occasionally  indulging  himself 
in  his  bed.  We  have  known  more  than  once  a  patient  declare 
himself  entirely  free  from  disease,  at  a  moment  when  he  was 
without  pulse*  and  within  a  very  short  period  of  dissolution.  In 
such  cases  the  foundation  of  the  healthy  play  of  every  organ  of 
the  body,  seems  to  be  silently  undermined ;  and  though  slow,  it 
is  not  the  less  certain  or  extensive;  indeed,  every  function  is 
gradually  so  diminished  that  it  cannot  be  recalled;  for  the  bane, 
has  silently  stolen  to  the  very  fountain  of  life,  and  so  polluted  its 
streams,  as  to  render  them  no  longer  fit  for  the  purposes  of  the 
system;  and  before  the  enemy  is  suspected,  the  citadel  is  on  the 
point  of  a  surrender.  This  peculiarity,  for  such  it  is,  may  also 
serve  to  distinguish  this  formidable  disease,  from  the  highly  bi- 
lious endemic  fever  of  the  West  Indies,  or  of  America. 

508.  Three  distinct  modes  of  attack,  as  we  have  just  observed, 
may  be  observed  in  the  yellow  fever ;  each  of  which  has  some- 
thing peculiar  to  itself;  these  varieties  must  arise  from  1.  The 
greater  or  less  degree  of  concentration  of  the  remote  cause,  or 
marsh  miasma.  2.  To  the  peculiarity  of  constitution.  3.  Or  to 
the  nature  and  degree,  of  the  exciting  cause.  Each  of  these  cir- 
cumstances will  necessarily  modify  to  a  certain  extent,  the  form, 
or  force  of  the  disease ;  accordingly  we  find  it  presenting  itself, 
1.  Where  the  disease  rapidly  runs  on  to  dissolution,  and  is  ac- 
companied by  black  vomit — this  form,  has  often  terminated  its 
career  within  three  days,  and  never  exceeding  the  fifth  day.  2. 
Where  the  disease  was  without  remissions;  or  when  they  were 
so  indistinct,  as  scarcely  to  be  observed.  In  this  form  of  the  dis- 
ease, the  course  is  not  run  with  so  much  rapidity  as  the  first; 
but  for  the  most  part  the  sufferings  of  the  patient  are  greater — 
there  is  no  perceptible  attempt  at  crisis ;  and  where  it  terminates 
fatally,  it  is  for  the  most  part  from  the  fifth,  to  the  seventh  day, 
and  is  not  necessarily  attended  with  black  vomit. t  3.  Where 
the  paroxysms  can  be  pretty  regularly  traced,  or  where  the  pe- 

*  In  no  disease  with  which  we  are  acquainted,  does  this  circumstance  obtain 
to  the  same  extent  as  in  yellow  fever — we  have  in  a  number  of  cases  known 
this  state  of  things  to  exist  for  many  hours  before  death.  During  this  period 
it  was  not  unusual  for  the  patient  to  be  in  full  possession  of  his  senses;  some- 
times even  without  pain,  or  the  smallest  anxiety  for  his  situation— nay,  when 
interrogated  as  to  his  feelings,  he  would  declare,  "  he  was  very  well,  much 
better,  or  expected  he  would  soon  be  well,  as  only  a  little  weakness  remain- 
ed." If  we  are  correct  in  our  observations,  this  more  especially  happened, 
where  this  disease  killed  without  the  intervention  of  black  vomit. 

•j-  This  form  of  the  disease  has  been  known  to  terminate  without  black  vomit; 
but  dissection  has  shown  that  this  fluid  has  been  formed,  though  not  rejected. 
It  was  also  observed  in  these  cases,  that  the  inflammation  of  the  stomach  was 
more  decided  and  extensive,  than  where  black  vomit  had  been  thrown  off. 
Was  the  stomach  prostrated  beyond  the  power  of  vomiting? 


YELLOW    FEVER.  157 

riods  of  exacerbation  are  not  so  entirely  uncertain ;  but  where 
there  is  stronger  evidences  of  an  inflammatory  diathesis,  than  in 
either  of  the  former ;  but  which  may  rapidly  change  if  not  ar- 
rested by  proper  remedies,  into  an  opposite  state,  and  terminate 
either  in  the  black,  or  the  coffee-ground  vomit — this  form  may 
terminate  within  five  days ;  but  if  checked,  it  may  run  on  to  the 
seventh,  ninth,  or  eleventh  day. 

509.  The  first  form  observes  no  regular  period  of  attack, 
though  the  evening  is  the  most  common.  It  invades  by  an  un- 
usual degree  of  languor  and  debility;  head-ache  more  or  less  in- 
tense ;  a  most  distressing  and  indescribable  sensation  about  the 
region  of  the  stomach.  It  is  rarely  preceded  by  severe  rigour, 
but  it  is  oftentimes  of  long  continuance;  it  is  not  followed  by 
great  reaction ;  the  heat  of  the  body  is  rarely  great,  but  is  of  a 
peculiar  kind,  giving  the  idea  of  acridiiy-or  pungency  to  the 
hand  that  feels  it.  The  pulse  is  apparently  weak,*  confined,  and 
giving  the  sensation  of  creeping.  The  face  assumes  a  character 
and  expression  that  belongs  exclusively  we  believe,  to  this  dis- 
ease ;  the  eyes  are  inflamed,  or  rather  severely  blood-shotten,  as 
it  is  called ;  and  have  a  look  of  peculiar  sadness,  anxiety,  and 
anguish ;  a  flushing  of  the  face  of  a  truly  characteristic  hue,  and 
of  a  singular  tone — a  reddish-brown  not  unlike  the  colour  of 
mahogany,  mixed  with  a  lividity,  especially  its  own.  It  is  diffi- 
cult, if  not  impossible,  to  convey  an  accurate  idea  of  this  appear- 
ance of  the  face;  but  so  impressive  are  its  characters  that  they  are 
never  forgotten,  after  having  once  been  seen.  So  truly  does  it 
indicate  yellow  fever  of  a  high  grade  that,  we  believe  with  peo- 
ple familiar  with  it,  it  would  be  sufficient  to  designate  the  disease. 
The  tongue  for  the  most  part  is  moist,  but  foul ;  the  thirst  in  the 
beginning  not  great,  at  least  rarely  severe.  As  the  disease  ad- 
vances, the  breathing  is  oftentimes  disturbed ;  becomes  hurried, 
and  appears  to  be  performed  with  a  distress  about  the  precordia. 
No  remission  takes  place,  although  a  trifling  abatement  of  symp- 
toms is  observed,  sometimes  about  ten  or  twelve  hours  from  the 
commencement  of  the  disease;  but  this  is  transient;  and  seems 
only  a  prelude  to  an  increased  severity  of  symptoms;  for  an 
aggravation  of  all  that  we  have  enumerated,  immediately  succeed 
this  attempt  at  remission.  The  eye  increases  in  sadness  of  ex- 
pression— it  is  the  eye  of  complete  hopelessness — a  burning  sen- 
sation is  now  felt  about  the  stomach,  and  the  patient  suddenly 
flinches  from  the  slightest  pressure  being  made  upon  it,  which 
emphatically,  locates  the  seat  of  mischief;  head-ache  is  augment- 

*  This  state  of  pulse  has  led  to  great  error  in  prescriptions — for  this  "  ap- 
parently weak  pulse,"  has  been  mistaken  for  an  absolutely  weak  pulse;  where- 
as it  is  only  the  "  depressed  pulse,"  and  requires  a  diametrically  opposite 
treatment.  This  fact  should  be  kept  in  mind.  (See  note  to  par.  352.) 


158  YELLOW    FEVER. 

ed,  sometimes  to  an  intense  degree;  the  countenance  becomes 
haggard,  and  of  most  sad  expression — marks  of  inflammation  are 
now  more  decided ;  the  gums  begin  to  swell  and  to  become  en- 
gorged with  blood,  and  easily  provoked  to  bleed.  The  condition 
of  the  tongue  now  is  variable;  sometimes  moist,  sometimes  dry, 
but  always,  or  with  very  few  exceptions,  foul  or  very  red.  Thirst 
either  moderate  or  intense.  Nausea,  which  perhaps  may  have 
existed  from  the  beginning,  is  now  increased;  but  there  is  rarely 
a  steady  vomiting  for  the  first  day  or  two,  or  even  perhaps  some- 
times longer.  The  discharges  from  the  stomach,  when  vomiting 
occurs,  are  rarely  bilious;  though  sometimes  porracious.* 

510.  The  fluids  discharged  are  for  the  most  part  clear,  or  par- 
take simply  of  the  colour  of  the  liquids  drank;  but  a  change  is 
soon  perceived  as  the  disease  advances ;  they  become  thick  and 
ropy ;  and  have  mixed  with  them,  a  dark-coloured  flaky  sub- 
stance, which  gives  the  first  intimation  that  the  stomach  is  about 
to  yield  to  the  force  of  the  disease;  for  these  flakes  are  part  of 
the  villous  coat  of  this  organ. t  The  patient  now  becomes  rest- 
less and  anxious  in  the  extreme ;  he  throws  himself  incessantly 
about,  as  if  in  the  hope  that  a  change  of  place  would  procure  a 
temporary  suspension  of  misery.  He  is  watchful — sleep  seems 

*  In  some  few  instances  of  the  mild  form  of  this  disease,  bilious  vomitings 
occurred — they  for  the  most  part  afforded  relief,  and  always  decidedly  marked 
a  disease  of  a  milder  and  more  tractable  kind,  than  where  this  did  not  occur — 
in  some  rare  instances,  a  vomiting  of  very  dark  or  black  coloured  bile  accom- 
panied the  first  symptoms  of  the  disease;  almost  all  of  these  recovered.  Dr. 
Smith  (a)  appears  to  be  under  an  error  in  regard  to  the  nature  of  yellow  fever, 
or  rather  in  the  order  of  and  nature  of  its  symptoms,  when  he  says,  "at  another 
time  the  disease  may  seize  with  peculiar  violence  upon  the  organs  of  secretion, 
and  especially  upon  those  which  belong  to  the  digestive  apparatus;  hence  the 
liver  may  suddenly  pour  forth  an  immense,  flow  of  bile,  so  vitiated  in  quality  as  to 
irritate  and  inflame  whatever  it  touches,  and  so  abundant  in  quantity  as  rapidly 
to  diffuse  itself  over  every  part  of  the  body,  and  to  tinge  almost  every  tissue  and 
every  fluid;  at  the  same  time  the  stomach  and  intestines  may  be  involved  in 
such  acute  disease  that  the  powers  of  life  may  be  exhausted  in  a  few  hours  by 
incessant  vomiting  and  unconquerable  purging;  thus  may  be  formed  another 
type  of  fever,  and  such  a  concurrence  of  symptoms  actually  occurs  in  the  yel- 
low fever  of  the  West  Indies." 

In  this  short  extract  several  errors  as  regards  the  nature  of  yellow  fever  pre- 
sent themselves;  first,  when  the  liver  is  acted  upon  in  an  especial  manner  by 
'  the  remote  cause,  it  has  always,  (at  least  in  this  country,)  marked  a  mild  form 
of  the  disease  as  has  just  been  observed;  second,  the  yellow  appearance  ob- 
served in  this  disease  appears  to  be  attributed  to  the  diffusion  of  bile — but  this 
is  not  so;  as  neither  the  eyes,  nor  the  urine  betray  its  presence  in  the  circu- 
lating fluids;  third,  we  have  never  had  occasion  to  observe  this  acrid  condition 
of  the  biliary  secretion,  spoken  of  by  Dr.  Smith. 

f  We  have  seen  these  dark  spots,  immediately  after  vomiting,  diffused  in  a 
large  quantity  of  almost  transparent  fluids;  but  when  suffered  for  a  time  to  be 
at  rest,  they  would  rise  and  float  upon  the  surface. 

(a)  A  Treatise  on  Fever,  p.  55. 


YELLOW    FEVER.  159 

to  have  forsaken  him ;  or  should  he  chance  to  slumber,  he  is 
suddenly  disturbed  by  internal  disquietudes,  and  awakes  to  re- 
newed and  increased  sufferings.  His  respiration  is  deep,  hurried, 
and  to  appearance  painful.  He  sighs  deeply  and  frequently,*  and 
is  disposed  to  faint  upon  the  smallest  disturbance,  or  the  slightest 
elevation  of  his  head.  A  clammy  sweat  breaks  out  sometimes 
about  the  head  and  neck;  which  neither  affords  relief,  nor  gives 
a  favourable  prognosis. 

511.  The  heat  of  the  body  is  rarely  increased;  and  the  pulse 
even  abates  in  frequency ;  in  the  commencement  of  the  attack, 
the  bowels  are  usually  confined;  the  urine  high-coloured,  turbid, 
and  in  small  quantity — indeed,  in  many  instances,  it  seems  gra- 
dually to  diminish  as  the  disease  advances;  so  much  so  some- 
times, as  to  be  entirely  wanting  at  last — where  this  has  obtain- 
ed, we  do  not  recollect  a  single  instance  of  recovery. 

512.  Delirium  is  by  no  means  an  usual  symptom  of  yellow 
fever;  it  however  occasionally  presents  itself;  sometimes  in  a 
very  mild,  at  other  times  in  a  most  ferocious  degree — when  it 
does  occur,  it  is  rarely  before  the  third  day,  and  it  may  then  be 
transient. 

513.  About  this  period,  (that  is,  of  three  days,)  the  patient's 
sufferings  appear  to  diminish,  and  the  system  to  undergo  an  in- 
sidious change — a  change,  which  has  but  too  often  imposed  upon 
the  inexperienced  in  this  disease — the  eye  now  nearly  regains 

'  *  Dr.  Physick  has  observed  that  the  following  symptoms  in  yellow  fever 
were  always  fatal:  1st,  those  patients  who  sighed  deeply  immediately  after 
waking,  and  before  they  had  recovered  the  power  of  speech;  2d,  those,  who 
complained  of  soreness  and  pain,  without  this  part  having  any  morbid  appear- 
ance; 3d,  those,  whose  arms  became  rigid;  and  4th,  those,  who  had  an  entire 
suppression  of  urine.  This  case  must  not  however  be  confounded  with  a  reten- 
tion of  urine,  as  this  is  not  a  very  unfrequent  condition  in  ordinary,  but  strongly- 
marked  fever — we  have  often  seen  this  in  the  very  acute  remittents  which  had 
run  on  beyond  their  usual  periods.  This  condition  of  the  bladder  has  been 
observed  by  Dr.  Tweedie,  (Clinical  Illustrations,  &c.  p.  32,)  who  says,  "from 
an  inactive  state  of  the  muscles  concerned  in  the  expulsion  of  the  urine,  accu- 
mulation in  the  bladder  often  takes  place;  so  that  in  all  cases  of  Severe  senso- 
rial  disturbance,  the  region  of  the  bladder  should  be  examined  at  each  visit,  as 
I  have  often  seen  great  additional  irritation  arise  from  this  cause."  On  these 
facts  he  makes  the  following  important  practical  remarks,  to  the  truth  of  which 
we  can  ourselves  bear  witness.  "  I  have  known  a  practitioner  thrown  off  his 
guard  completely,  by  the  patient  passing  small  quantities  of  urine  uncon- 
sciously, which  not  unfrequently  happens  when  the  bladder  is  over-distended. 
Appropriate  measures  should  be  adopted  before  such  an  accumulation  takes 
place,  as  it  not  only  proves  a  source  of  distress,  but  the  sudden  removal  of  so 
large  a  quantity  by  the  catheter,  in  the  advanced  stages  of  fever,  is  sometimes 
followed  by  an  alarming  collapse,  from  which  it  is  not  easy  to  rouse  the  pa- 
tient." And  he  might  have  added,  that  even  sudden  death  has  followed  this 
operation  from  a  destruction  of  the  bladder  itself.  It  may  be  useful  in  forming 
a  prognosis  in  fever,  that  suppression  of  urine  is  much  more  dangerous  than  a  re- 
tention, as  the  former  rarely  occurs  but  in  cases  of  high  cerebral  irritation. 


160  YELLOW    FEVEH. 

its  accustomed  brightness,  and  the  countenance  assumes  its  usual 
cheerfulness  and  serenity;  but  the  practised  observer  is  but  too 
well  acquainted  with  the  treachery  of  these  appearances;  he  ob- 
serves a  yellowness  spread  itself  over  the  body  and  neck,  which 
too  emphatically  bespeaks  a  fatal  issue  to  the  disease.  The  fever 
and  external  heat  now  subside;  the  pulse  even  becomes  fuller, 
and  slower ;  and  were  the  wrist  presented  for  the  examination 
of  one  unacquainted  with  the  other  circumstances  connected  with 
the  case,  he  would  most  probably  declare  it  to  be  in  a  natural 
state. 

514.  The  skin  is  dry,  and  of  a  peculiar  feel;  a  roughness  or 
harshness  possesses  it,  that  would  seem  to  declare  that  sweating 
was  not  one  of  its  functions — the  gums  increase  in  intensity  of 
colour,  become  spongy,  and  occasionally  bleed — the  vomiting 
is  more  troublesome,  and  continues  to  show  still  more  decidedly, 
that  the  villous  coat  is  separating ;  the  distress  at  stomach  is  re- 
newed with  augmented  force;  and  the  patient  discovers  the  ut- 
most misery  and  wretchedness.    This  state  of  things  may  remain 
for  one,  two,  or  even  three  days,  without  much  alleviation  or 
change — but  at  the  end  of  this  time,  without  a  favourable  altera- 
tion take  place,  the  heat  of  the  body,  and  especially  that  of  the 
extremities,  is  found  to  be  dissipated ;  the  pulse  is  either  almost, 
strictly  speaking,  natural,  or  is  slow  and  regular — the  yellowness 
increases — the  anxiety  becomes  extreme  and  inexpressible — the 
vomiting  is  now  indomitable ;  and  the  long  looked  foij,  and  ter- 
rible black  vomit,  at  last  appears. 

515.  There  are  shades  of  colour  in  this  black  discharge,  de- 
pending chiefly,  we  believe,  on  the  speed  with  which  this  dis- 
ease runs  its  course — when  its  progress  is  rapid,  the  matter  of 
the  vomit  will  be  very  black,  and  resemble  a  strong  mixture  of 
soot  and  water;  when  less  so,  it  will  appear  like  the  grounds  of 
coffee ;  and  when  still  slower,  the  black  will  be  less  intense,  or 
consist  sometimes  of  merely  dark-coloured  mucous  flakes.  When 
these  flakes  appear  early  in  the  disease,  it  always  presages  a  se- 
vere one  ;  and  they  always  increase  when  the  disease  is  making 
a  fatal,  or  even  a  highly  dangerous  progress.  Blood  is  sometimes 
found  with  the  fluids  thrown  from  the  stomach,  which  may  pro- 
ceed either  from  the  stomach  itself,  or  from  the  throat  or  gums. 
At  times,  the  quantity  of  fluid  vomited  is  truly  surprising,  and 
would  appear  much  to  exceed  that  taken  down;  and  towards  the 
close  of  the  disease  it  seems  to  be  ejected  almost  without  effort. 
This  discharge  seems  to  bring  some  relief  for  a  moment;  but  it 
is  very  transitory;  for  the  stomach  is  obliged  again  to  empty  it- 
self, so  soon  as  it  is  again  distended.     The  stomach  appears  at 
this  time  too  much  prostrated  to  experience  the  sensation  of 
nausea — at  least  we  have  known  patients  declare  they  were  not 


YELLOW    FEVER.  161 

sick  at  stomach,  the  moment  before  they  would  vomit.  There 
is  almost  always  a  "  vomiting  of  wind,"*  before  black  vomit 
makes  its  appearance — this  we  believe  to  be  owing  to  the  ex- 
trication or  secretion  of  gas  within  the  stomach,  which  by  dis- 
tending it,  causes  an  effort  similar  to  vomiting.  We  have  almost 
invariably  observed  the  disease  to  terminate  in  black  vomit,  or 
fatally,  where  this  symptom  has  been  present.  It  is  a  most  dis- 
tressing condition  of  the  stomach,  and  evidences  a  severe  inflam- 
mation of  this  organ. 

516.  At  this  stage  of  the  disease,  that  is,  at  the  time  when 
black  vomit  is  about  to  appear,  the  bowels  almost  always  become 
loose;  the  evacuations  are  tenacious,  and  much  resemble  tar,  both 
in  colour  and  consistency.     In  our  early  acquaintance  with  this 
disease  in  our  city,  this  appearance  of  the  stools  was  by  some 
considered  favourable;  it  looked  like  getting  rid  of  a  highly  irri- 
tating and  offensive  matter,  for  the  removal  of  which,  purging 
was  immediately  instituted;  and  the  patient  sometimes  expired, 
under  the  operation. 

517.  The  gums  are  now  extremely  soft,  and  discharge,  or  ra- 
ther there  oozes  from  them  blood,  which  has  lost  the  power  of 
coagulation;  this  oozing,  however,  is  not  always  confined  to  the 
gums ;  the  nose,  ears,  arms,  and  various  other  parts  of  the  body, 
sometimes  participate  in  it.     Sordes  now  encrust  the  teeth;  the 
pulse  may  either  cease  altogether,  or  become  so  frequent  and 
feeble,  as  scarcely  to  be  counted;  a  low  muttering  delirium,  coma, 
or  convulsion,  may  close  the  scene. 

518.  We  have  endeavoured  in  the  history  of  the  symptoms  of 
yellow  fever,  to  give  an  account  of  its  ordinary  march,  to  a  fatal 
issue,  where  the  disease  was  allowed  to  run  its  own  course.  We 
do  not  pretend  to  enumerate  all  the  symptoms  which  may  occur, 
as  they  will  necessarily  be  modified  by  contingencies.   We  trust 
we  have  kept  pretty  faithfully  to  the  order  of  progress ;  though 
we  are  sensible  they  do  not  invariably  observe  the  same  succes- 
sion— for  instance,  we  have  known  the  black  vomit  precede  the 
general  diffusion  of  yellowness — but  we  have  just  observed  such 
cases  are  rare ;  and  even  when  they  do  occur,  a  tinge  of  yellow 
about  the  corners  of  the  mouth  and*  neck  may  be  observed,  be- 
fore the  vomiting  of  black  matter  comes  on,  if  they  be  carefully 
observed  in  a  strong  light;  and  as  far  as  our  observations  have 
extended,  they  mark  the  approach  of  the  event  as  decidedly,  as 
when  the  diffusion  is  more  general — especially,  if  the  skin  of  the 
forehead  be  tinged ;  is  drawn  tightly  over  the  frontal  bone ;  and 

*  This  may  appear  an  awkward  expression,  but  it  is  truly  characteristic, 
and  exist  as  a  fact;  for  the  stomach  discharges  at  this  time  a  considerable  quan- 
tity of  gas,  (the  nature  of  which  we  believe  has  never  been  ascertained,)  by 
the  same  mechanism  it  does  fluids  or  solids  upon  other  occasions. 

21 


162  YELLOW    FEVER. 

is  shining.  Again  we  have  seen  an  increase  of  restlessness  after 
black  vomit  has  commenced,  though  it  is  generally  the  re- 
verse, &c. 

519.  It  may  not  be  amiss  to  remark  here,  that  fatal  as  the 
symptom  of  black  vomit  is,  it  is  not  invariably  so — as  we  have 
seen  more  than  one  instance  of  recovery  after  this  had  taken 
place;  this  has  been  more  frequently  witnessed  in  children  than 
in  adults.  Bleeding  from  various  parts  of  the  body  is  also  a  ter- 
rible symptom ;  but  instances  of  recovery  from  this  have  much 
more  frequently  occurred  than  from  black  vomit — indeed,  in  se- 
veral instances  in  the  fever  of  1798,  it  appeared  useful ;  at  least 
there  was  from  the  moment  of  its  taking  place  an  evident  amend- 
ment, and  finally  recovery.  The  recoveries  after  the  black  vomit 
are  both  rare,  and  slow — the  abatement  of  the  puking  is  gradual; 
the  black  matter  ceases  to  be  thrown  up,  but  the  stomach  conti- 
nues to  dislodge  other  matters  from  it  for  some  time;  and  a  long 
period  before  this  organ  recovers  its  tone — in  one  instance  which 
we  witnessed,  more  than  three  months  elapsed  before  it  could 
bear  the  ordinary  food  of  the  table.     The  patient  being  many 
hours  without  pulse,  is  not  necessarily  a  fatal  symptom;  we  have 
seen  instances  of  recovery  where  this  had  obtained. 

Treatment. 

520.  Having  thus  given  as  condensed  a  history  of  yellow 
fever  as  we  were  capable,  we  shall  proceed  to  consider  the 
method  of  cure.     In  doing  so  we  must  remark,  that  this  dis- 
ease in  a  most  especial  manner  calls,  not  only  for  appropriate 
remedies,  but  also  for  the  most  prompt  application  of  them.  And 
we  have  authority  to  say,  that  where  the  patient  does  not  delay 
too  long  before  he  seeks  advice,  that  it  is  a  manageable  disease, 
in  more  instances  than  is  generally  supposed.     But  to  render  it 
so,  no  time  must  be  lost — it  must  be  instantly  subjected  to  a  ri- 
gorous discipline;  or  it  soon  becomes  so  intractable,  as  to  bid  de- 
fiance to  every  attempt  at  subjugation.     We  have  noticed  three 
different  forms  under  which  this  disease  presents  itself;  this  how- 
ever will  not  embarrass  the  method  of  cure ;  as  each  of  these  is 
virtually  the  same  disease,  and  require  almost  thesame  remedies — 
the  difference  consisting  chiefly  in  the  extent  to  which   the  re- 
medies must  be  carried,  rather  than  a  difference  in  the  remedies 
themselves.     In  the  first  form  there  is  more  likelihood  of  error 
than  in  the  other  two ;  and  which  if  committed,  will  at  once  seal 
the  patient's  doom. 

521.  In  our  description  of  this  form,  we  noticed  two  circum- 
stances, which  we  here  repeat,  that  they  may  not  be  lost  sight 


YELLOW    FEVER.  163 

of:  1st,  the  appearance  of  weakness  in  the  pulse;*  2d,  the  dis- 
ease not  being  ushered  in  by  a  regular  chill ;  but  rather  a  cold- 
ness of  long  continuance  sometimes,  and  which  is  not  followed 
by  violent  reaction.  From  the  two  circumstances  just  stated 
obtaining  in  this  form,  a  wrong  conclusion  has  been  drawn  as  to 
the  state  of  the  system;  and  stimulants  unfortunately  have  been 
employed ;  or  if  not,  proper  depletion  had  not  been  resorted  to. 
We  must  not  therefore  be  deceived  by  this  marked  state  of  the 
pulse,  and  make  us  employ  improper  remedies;  for  these  must 
consist  of  bleeding  and  purging,  and  powerfully  exciting  the 
skin,  when  its  temperature  is  below  the  natural  standard — this 
is  best  done  by  the  application  of  external  warmth  in  the  usual 
various  ways — as  bottles  of  hot  water,  hot  bricks,  warm  blan- 
kets, sinapisms,  &c.  This  is  a  congestive  state. 

522.  The  patient  should  be  supported  during  the  chilly  state, 
by  artificial  heat  applied  to  his  body,  by  means  of  heated  blan- 
kets, &c.  as  just  stated,  until  the  system  begins  to  react;  the 
warm  bath,  when  practicable,  and  when  it  will  not  occasion  too 
much  delay,  may  be  advantageously  employed — a  vein  should 
then  be  opened,  and  as  much  blood  taken  as  the  patient  can  well 
spare  at  the  moment — the  quantity  should  be  very  much  regu- 
lated by  the  effects — that  is,  where  a  few  ounces  have  been  lost, 
and  the  pulse  is  found  to  rise  and  become  more  active,  we  should 
permit  the  blood  to  flow  until  a  decided  reduction  is  made  of  its 
lately  acquired  force — or,  until  it  becomes  really  feeble,  or 
there  is  a  regular  abatement  of  symptoms.  If  the  pain  attending 
the  disease,  especially  head-ache,  be  very  severe,  we  sometimes 
shall  find  it  relieved  in  proportion  to  the  flowing  of  the  blood. 
But  if  he  have  an  obscure  head-ache  with  very  red  eyes,  with 
this  depressed  state  of  the  pulse,  it  is  very  possible,  we  shall  con- 
vert a  dull  obtuse  pain  into  a  very  acute  one.  This  change  was 
far  from  being  unusual  in  the  yellow  fevers  which  visited  Phila- 
delphia in  the  various  years  in  which  it  made  its  appearance. 
And  in  1793,  especially,  it  had  an  unfavourable  effect  upon  the 
public  mind;  for  it  made  it  hostile  to  depleting  remedies — this 
prejudice  was  however  but  transitory;  it  yielded  as  soon  as  the 
cause  was  understood. 

•  We  have  before  remarked,  that  the  pulse  of  this  form  of  yellow  fever  is 
what  we  have  termed  upon  good  authority,  the  oppressed  or  depressed  pulse; 
a  conditibn  of  the  artery  which  requires  depletion  even  more  certainly  than 
the  strong,  full  pulse.  It  requires  however  to  be  understood;  we  have  at- 
tempted an  explanation  in  note  to  par.  352.  This  pulse  is  sure  to  be  convert- 
ed by  depletion,  into  the  strong,  full  pulse,  in  a  few  minutes;  hence  we  have 
directed,  that  after  this  ensues,  the  abstraction  of  blood  must  be  continued, 
until  the  force  of  the  artery  is  positively  weak;  for  it  was  only  relatively  so  be- 
fore. This  kind  of  pulse  is  felt  in  apoplexy,  and  in  phlogosis  of  the  lungs;  or 
sometimes  even  in  violent  fits  of  asthma. 


164  YELLOW    FEVER. 

523.  We  have  noticed,  that  the  bleeding  would  very  often 
procure  an  abatement  of  the  most  distressing  symptoms,  when 
early  resorted  to,  and  sufficiently  employed;  nor  was  this  all ;  it 
also  disposed  the  disease  to  assume  a  greater  regularity  of  pa- 
roxysm; or  in  other  words,  procured  a  disposition  to  remission; 
and  although  there  was  not  much  regularity  in  the  accessions, 
still  they  were  sufficiently  marked,  as  to  lead  to  the  hope,  of 
converting  this  disease  into  one  of  more  regular  type,  and  of 
milder  grade — and  this  sometimes  very  early  took  place.    It  was 
therefore,  always  looked  upon  as  favourable,  where  there  was 
strong  exacerbations,    with  decided  remissions,  after   the    de- 
pressed state  with  which  it  commenced.     In  this  form  the  dis- 
ease was  more  palpable,  and  open;  and  although  it  would  re- 
quire the  use  of  the  lancet  many  times,  before  it  could  be  sub- 
dued, yet  it  was  in  a  form  that  was  much  more  manageable,  than 
where  the  bleeding  and  other  remedies  failed  to  give  the  disease 
this  new  character. 

524.  Where  bleeding  failed  to  give  immediate,  though  tempo- 
rary relief,  or  to  unload  the  system  so  that  it  could  pretty  freely 
react,  the  disease  scarcely  ever  failed  to  run  its  course  in  a  short 
time  in  spite  of  every  other  attempt  at  opposition.    The  stomach 
would  soon  give  way ;  and  death  be  ushered  in  by  black  vomit. 
Some  of  the  West  India  practitioners,  especially  Jackson,  carried 
bleeding  to  a  much  greater  extent  than  has  been  ventured  upon 
in  this  country — he  almost  always  bled  to  fainting,  when  he  saw 
the  patient  after  the  first,  six  or  eight  hours  after  the  attack,  and 
as  he  declares,  with  the  most  happy  and  decided  advantage.    In 
directing  bleeding  in  the  form  of  the  disease  under  consideration, 
we  must  be  understood  as  having  in  view,  its  commencement — 
as  for  the  most  part,  if  the  patient  had  been  ill  for  twenty-four, 
or  thirty  hours,  it  was  truly  a  forlorn  hope  to  attack  it.     For 
after  this  period  the  debility  and  disorganization  become  so  de- 
cided, and  irreclaimable,  that  every  effort  to  arrest  their  further 
progress  was  totally  unavailing.     It  is  vain  we  give  tonics,  or 
urge  stimulants;  they  both,  indeed  appear  but  to  hasten  the  ca- 
tastrophy. 

525.  After  taking  as  much  blood  as  the  state  of  the  system  will 
justify,  or  the  exigency  of  the  existing  symptoms  require,  we  are 
strictly  to  put  in  use  all  the  rules  we  have  laid  down  for  the  ge- 
neral management  of  fever;  for  in  no  kind  are  they  more  neces- 
sary or  decidedly  useful,  than  in  this.     We  must  next  pay  at- 
tention to  the  state  of  the  bowels;  we  have  said  that  for  the  most 
part  they  are  costive  or  tardy  in  this  disease — we  should  select 
for  exhibition  the  most  certain  of  the  purgatives;  and  they  should 
be  exhibited  in  divided  doses,  rather  than  in  large  ones.   In  this 
wav  they  are  not  only  more  certain,  but  also  less  offensive. 


YELLOW    FEVER.  165 

Calomel*  in  form  of  pills  is  perhaps  the  least  exceptionable,  and  of 
the  most  decided  efficacy — should  they  fail  after  a  few  hours,  of 
procuring  copious  evacuations,  they  may  be  followed  by  castor  oil, 
or  calcined  magnesia,  drinking  after  it  lemonade;  or  magnesia  and 
Epsom  salt  may  be  given,  until  the  effect  be  produced;  and  these 
may  very  often  be  advantageously  aided  by  stimulating  injections.! 
It  must  be  remarked,  we  are  not  to  be  deterred  from  giving  purga- 
tives because  a  moderate  sickness  of  stomach  may  accompany  the 
disease;  for  should  we  yield  even  for  a  few  hours  to  this  symptom, 
we  should  have  the  mortification  of  seeing  it  augment  without 
the  advantage  of  having  the  purgative  in  possession  of  the 
bowels — we  have  rarely  found  the  nausea  of  this  disease  in- 
creased by  these  medicines.  The  only  difference  we  would  ad- 
vise, is,  the  use  of  the  calomel  alone  in  grain  doses,  aided  by  re- 
peated injections. 

526.  When  the  bowels  are  freely  purged,  we  may  desist  from 
large  doses  of  medicine  ;  but  we  must  be  careful  to  maintain  the 
operation  by  occasional  exhibitions  of  it — for  this  purpose  a  pill 
of  calomel  may  be  given  once  in  four  or  six  hours;  or  small  doses 
of  castor  oil,  with  great  benefit.  Upon  bleeding,  and  a  lax  con- 
dition of  the  bowels,  we  must  place  our  chief  reliance;  and  they 
must  be  employed  whenever  the  system  either  reacts  in  form  of 
regular  paroxysms,  or  in  occasional  exacerbations.  We  must 
not  limit  the  time  of  repetition  of  this  remedy  by  its  use  in  or- 
dinary diseases;  we  must  be  governed  by  the  violence  of  symp- 
toms, and  by  the  period  in  which  the  fever  runs  its  course — the 
procrastination  of  even  a  single  hour,  may  have  important  con- 
sequences attached  to  it.  We,  therefore,  bleed  whenever  the 
symptoms  increase  in  violence,  (other  things  being  equal,)  if  that 
be  every  few  hours — we  well  remember  giving  our  friend  Dr. 
Physick  twenty-three  bleedings  in  five  days  with  the  happiest 
effect.  And  we  have  witnessed  where  the  blood  first  drawn  was 
dissolved,  J  yet  the  subsequent  bleedings  showed  decided  marks 


*  R.  Calomel  ppt.      -        -        gr.  x. 
Conserv.  rosar.         -  q.  s. 

M.  f.  pil.  iij. 
One  of  these  to  be  taken  every  hour. 


Take  Calomel,        -        -     10  grains. 
Conserve  of  roses,  sufficient  to 
make  three  pills. 


f  One  of  the  simplest  and  best  we  believe  at  this  time,  is,  a  pint  of  luke- 
warm water,  and  a  large  table-spoonful  of  common  salt.  Should  this  fail  in 
operating  for  twenty  minutes,  it  may  be  repeated. 

t  Dissolved  blood,  is  that  condition  of  this  fluid,  in  which  no  separation  of 
its  constituent  parts  take  place;  and  where  the  coagulating  lymph  has  lost  its 
power  of  coagulation.  The  whole  mass  after  standing  for  some  hours  can  be 
poured  from  one  vessel  into  another,  like  thick  molasses.  This  state  of  the 
blood  was  looked  upon  by  Dr.  Rush  as  a  mark  of  the  highest  inflammation  to 
which  the  system  could  go,  without  being  in  a  state  of  gangrene.  If  this  ob- 
servation be  confined  to  the  early  part  of  this  disease,  we  have  reason  to  be- 


166  *  YELLOW    FEVER. 

of  inflammation.  One  instance  is  still  fresh  in  our  memory, 
where  six  ounces  of  dissolved  blood  were  drawn  at  the  first 
bleeding,  on  the  first  day  of  the  disease;  yet  after  this  the  sys- 
tem reacted  so  powerfully,  as  to  require  twelve  more  bleedings 
to  tranquillize  it;  the  patient  recovered  rapidly. 

527.  We  must  not  be  deterred  from  the  employment  of  de- 
pleting remedies  by  the  semblance  of  weakness — it  is  a  most  fal- 
lacious sign;  and  where  it  has  been  respected  in  the  commence- 
ment of  the  disease,  it  has  been  the  death  of  thousands.     There 
is  great  debility  in  yellow  fever;  the  patient  is  wont  to  faint 
early  in  the  attack,  when  disturbed,  or  placed  in  an  erect  posi- 
tion;  but  this,  instead  of  forbidding  bleeding,  calls  loudly  for 
it — we  have  very  many  times  witnessed  the  patient  strengthened 
by  the  loss  of  a  large  quantity  of  blood,  and  free  purging.      So 
long  then  as  the  pulse  is  either  depressed   and  tense,  preter- 
naturally  firm  and  slow,  or  very  active  and  corded,  we  are  im- 
periously called  upon  to  deplete.     In  the  first  instance,  the  pulse 
will  rise,  and  be  invigorated;  in  the  second,  it  will  increase  in 
frequency,  and  become  softer;  and  in  the  third,  it  will  become 
less  quick,  and  more  open.     There  is  something  remarkable  in 
the  strong  tendency  which  this  disease  has  to  disorganization 
when  permitted  to  run  its  course,  which  we  have  said  was  from 
three  to  five  days — it  marks  the  highest  grade  of  inflammatory 
action;  and  which,  if  not  subdued  by  prompt  and  appropriate 
remedies,  will  end  most  speedily  in  death.     The  employment  of 
proper  evacuations  will  almost  always  protract  the  hour  of  dis- 
solution; by  which  means  we  are  sometimes  enabled  to  gain  a 
victory  over  the  disease — for  if  it  moderate  in  violence,  we  have 
a  greater  opportunity  afforded  us,  to  yield  the  needed  succour. 
While,  on  the  contrary,  if  the  patient  has  been  entirely  neglected, 
or  what  is  worse,  if  he  has  been  treated  with  cordial  or  stimu- 
lating remedies,  he  has  rarely  lived  to  see  the  fifth  day,  and 
very  often  has  expired  on  the  third. 

528.  If  it  have  so  happened  that  a  day,  or  two  at  furthest,  has 
been  lost  to  the  application  of  remedies,  we  very  rarely,  (in  this 
form  of  the  disease,)  have  it  in  our  power  to  retrieve  them — 
but,  although  the  chance  of  success  is  very  slender,  the  patient 
must  not  be  abandoned.     We  are,  however,  persuaded,  that 
even  here  the  same  kind  of  remedies  are  necessary,  though  in  a 
much  less  active,  or  extensive  degree;  very  small  bleedings, 
with  gentle  purging,  have  succeeded  sometimes  when  the  system 

lieve  his  observation  correct,  as  the  case  alluded  to  in  the  text,  seems  to  con- 
firm. But  it  must  not  always  be  regarded  as  a  sign,  that  blood-letting  is  the 
proper  remedy  in  the  disease  in  which  it  may  appear;  for  in  the  last  stages 
of  yellow  fever,  the  blood  will  exhibit  the  same  phenomenon;  and  also  in 
scurvy. 


YELLOW    FEVER.  167 

seemed  fast  hurrying  to  dissolution.  We  should,  therefore, 
employ  them  as  long  as  there  is  the  least  vigour  in  the  arterial 
system,  only  proportioning  the  quantity  of  the  bleeding,  and 
the  extent  of  the  purging  to  the  existing  state  of  the  system. 
Sometimes  two  or  three  ounces  of  blood  have  been  drawn  with 
evident  advantage;  and  this  has  several  times  been  repeated  at 
two,  three,  or  four  hours  interval,  until  the  system  has  reacted 
with  renewed  force,  and  the  patient  has  escaped  from  death,  by 
these  small,  and  well-timed  bleedings — what  led  to  this  practice 
was  observing  recoveries,  after  haemorrhages  from  various  parts 
of  the  body,  had  taken  place. 

529.  Although  the  pathology  of  this  disease,  was  in  part  un- 
derstood in  1793,  and  clearly  in  1798,  yet  it  did  not  lead  to  the 
free  use  of  leeches.     The  numerous  post  mortem  examinations 
made  by  Dr.  Physick  in  the  Yellow  Fever  Hospital,. at  Bush- 
hill  in  1793,  and  at  the  City  Hospital  in  1798,  convinced  almost 
every  body,  that  a  high  grade  of  inflammation  of  the  mucous 
membrane  of  the  stomach,  was  the  true  cause  of  the  disease. 
Hence  the  almost  universal  employment  of  the  lancet,  and  of 
purging  in  this  complaint.     Notwithstanding  the  importance  of 
these  facts,  and  the  general  truth  of  the  indications  they  led  to, 
we  had  yet  to  learn,  that  many  of  the  remedies  employed  to  ful- 
fil them,  tended  rather  to  aggravate,  than  to  abate  the  inflamma- 
tion of  the  stomach;  such  for  instance,  as  all  the  very  active,  or 
rather  drastic  purgatives,  so  liberally  employed;  but  more  es- 
pecially, the  directly  stimulating  articles  resorted  to  by  soms, 
under  the  impression  it  was  a  form  of  typhus,  and  required 
bark,  wine,  ammonia,  &c.  &c. 

530.  But  we  may  here  ask  if  this  practice  be  not  adopted,  to 
what  shall  we  have  recourse?    There  are  but  two  other  choices, 
either  to  do  nothing,  or  what  is  still  more  decidedly  mischiev- 
ous, to  stimulate  with  wine,  brandy,  or  volatile  alkali.     Exter- 
nal stimuli  may  be  advantageously  used,  however,  at  this  pe- 
riod ;  one  of  the  best  of  these  is  heat — this  may  be  applied  in 
various  ways — by  warmed  articles  of  covering,  heated  bricks, 
jugs  or  bottles  of  warm  water,  &c. — sinapisms  to  the  feet  and 
ankles,*  legs  wrapped  in  flannels  wetted  with  warm  spirit  of  tur- 
pentine, &c. 

.  531.  We  are  of  opinion,  (which  however  we  confess  to  have 
derived  only  from  analogy,)  that  the  occasional  loss  of  a  few 
ounces  of  blood  from  the  region  of  the  stomach  by  leeches, 
would  be  of  the  most  prompt  and  extensive  benefit.  The  cutting 

*  In  the  use  of  these  articles  great  care  should  be  taken,  that  they  do  not 
remain  on  the  part  longer  than  to  exert  a  rubefacient  effect.  For  if  permitted 
to  stay  too  long,  a  gangrene  of  the  part  may  ensue. 


168  YELLOW    FEVER. 

short  of  the  paroxysms  of  the  remittent  form  of  fever  by  leech- 
ing over  the  stomach,  which  almost  amounts  to  certainty,  leads 
us  to  the  persuasion,  that  it  would  be  as  useful  in  yellow  fever; 
especially,  when  as  large  draughts  of  blood  had  been  made  from 
the  general  system,  as  it  would  well  bear ;  or  where  the  disease 
had  been  neglected,  and  the  abstraction  of  blood  from  the  arm 
might  be  thought  ineligible;  or  where  it  presented  itself  in  a 
milder  form.  After  this  we  might  blister  over  the  stomach,  or 
what  is  as  effectual,  and  more  prompt,  a  plaster  composed  of 
ground  mustard  and  spirit  of  turpentine ;  this  must  be  permitted 
to  remain^  until  the  patient  complain  of  the  intensity  of  its  ac- 
tion. The  bowels  must  be  evacuated  by  mild  purgatives,  as  cas- 
tor oil,  weak  solution  of  Epsom  salt,  or  magnesia  in  milk — these 
to  be  aided  by  injections. 

532.  As  the  stomach  is  very  frequently  sick  in  the  early  part 
of  the  disease,  care  should  be  taken  not  to  increase  it  by  the  ex- 
hibition of  improper  articles — all   stimulating  teas  should   be 
avoided;  as  that  of  mint,  ginger,  or  chamomile;  in  general,  the 
surest  relief  is  obtained,  by  not  allowing  the  patient  to  fill  his 
stomach  with  any  fluid — cold  water,  one  of  the  best  drinks,  is  re- 
jected very  often  with  great  violence,  when  given  in  a  large  quan- 
tity; it  should  therefore  be  given  by  the  spoonful — indeed,  any 
very  cold  drink  seems  to  disagree  with  the  patient,  if  given  too 
freely,  or  in  too  great  quantities ;  while  tepid  or  lukewarm,  will 
be  retained.  Ice  swallowed  in  small  portions,  is  very  acceptable. 
Yet  we  found  nothing  so  uniformly  agree  with  the  stomach  as  a 
pretty  strong  solution  of  gum  Arabic  in  water  in  small  quantities 
at  a  time;  small  quantities  of  milk  and  water,  frequently  repeat- 
ed ;  rich  toast  tea ;  or  lime  water  and  milk. 

533.  When  head-ache  is  severe,  cold  applications  have  been 
found  very  serviceable;  they  may  be  frequently  renewed,  or  per- 
manently maintained  on  the  head.*    The  best  mode  of  conduct- 
ing this  is  by  filling  a  large  bladder  two-thirds  full  with  cold 
water,  to  which,  if  necessary,  a  lump  of  ice  may  be  added — the 
bladder  is  then  tied  and  placed  on  the  head — should  the  hair  be 
thick,  it  may  be  best  to  thin  it,  or  to  cut  it  off.   Should  there  be 
great  heat  of  skin,  which  is  sometimes  the  case  even  in  this  form 
of  the  disease,  especially,  after  depletion  has  been  freely  employ- 
ed; and  the  fever  is  assuming  a  more  regular  form,  great  com- 
fort as  well  as  advantage  is  found  from  sponging  the  body  and 
arms,  with  cold  water;  or  should   there  be  great  sensibility  of 
skin,  or  cough,  with  tepid  water.     And  we  have  seen   in  this 

*  The  benefit  of  this  valuable  application  is  oftentimes  destroyed,  by  not 
having  it  properly  employed.  It  is  almost  always  kept  too  long  at  a  time  upon 
the  head,  whereas,  it  should  be  removed  as  soon  as  the  head  becomes  cold;  and 
only  renewed,  when  the  head  becomes  again  hot,  or  the  pain  severe. 


YELLOW    FEVEH.  J6ft 

state  of  the  system  much  benefit,  from  having  the  hands  of  the 
patient  kept  in  basons  of  cold  water,  until  their  temperature  has 
been  well  reduced  by  it — this  can  be  repeated  as  the  occasion 
may  require-^by  this  process,  indeed,  the  heat  of  the  whole 
body  appears  to  be  reduced. 

534.  In  the  other  two  forms  of  the  disease  which  we  have  no- 
ticed, the  plan  of  cure  is  so  conformable  to  the  first,  that  we  need 
not  enter  into  a  detailed  account  of  it — we  must,  however,  obi 
serve,  that  like  the  former,  almost  every  thing  depends  upon  the 
promptitude  with  which  the  remedies  are  employed.    In  the  se- 
cond form  the  alleviation  of  the  symptoms  is  more  manifest,  than, 
in  the  first,  that  is,  it  is  easier  to  procure  remissions — the  heat  of 
the  skin  is  in  general  more  intense,  and  the  patient  bears  bleed-, 
ing  and  other  depleting  remedies  better  than  in  the  first;  and 
when  an  impression  is  made  upon  the  disease  it  is  more  easily 
maintained — the  disease  may  be  protracted  until  the  seventh, 
ninth,  or  eleventh  day,  or  even  longer,  and  may  at  these  ad- 
vanced periods  terminate  by  a  regular  crisis,  or  in  death.     In 
this  form  the  good  effects  of  cool  air,  sponging,  and  the  applica- 
tion of  cold  water  to  the  hands  and  head,  are  more  evident  than 
in  the  former.    The  stomach  does  not  yield  so  soon ;  and  the  is- 
sue by  black  vomit,  is  either  longer  protracted,  or  does  not  take 
place,  though  death  may  ensue.     This  form  also  requires  more 
extensive  purging;  and  the  evacuations  are  frequently  bilious,. 
Haemorrhages  are  not  so  frequent. 

535.  In  the  third  form  we  have  said,  the  inflammatory  symp- 
toms are  evident;  that  is,  there  is  considerable  heat  of  skin, 
strong,  firm,  full  pulse,  flushed  face,  red  eyes,  tongue  white  and 
furred,  and  great  soreness  over  the  region  of  the  stomach  when 
pressed;  more  certainty  in  the  periods  of  exacerbation,  or  more 
distinct  remissions.     This  form  seems  more  open  and  of  easier 
management  than  the  two  former,  and  resembles  more  the  high 
grade  of  a  regular  bilious  remittent.  But  if  the  first  two  or  three 
paroxysms  be  allowed  to  pass  without  opposition,  the  system 
may  be  prostrated — the  pulse  becomes  slower,  softer,  and  weak-? 
er — the  blood  seems  to  retire  from  the  surface- — the  body  becomes 
cool  and  pale ;  the  face  assumes  a  leaden  hue ;  the  eyes  remain 
injected,  with  also  a  strong  tinge  of  yellow;  the  tongue  dry  and 
brown;  the  stomach  sick  and  disposed  to  vomit;  the  matters 
thrown  up  have  the  dark  mucous  flakes  mixed  with  them ;  hic- 
cough, cold  extremities,  and  black  vomit — 4he  bowels  become 
loose,  and  the  evacuations  are  sometimes  passed  involuntarily-— *• 
coma,  and  slight  delirium.     Notwithstanding  this  terrible  train 
of  symptoms,  the  disease  runs  a  longer  course  than  the  two  for- 
mer— and  although  the  tendency  to  disorganization  is  equally  to 

22 


170  YELLOW    FEVER- 

be  apprehended,  it  is  not  equally  rapid — the  inflammation  which 
attends,  is  not  so  excessive  though  more  evident  and  palpable; 
and  the  system  seems  to  lose  its  powers  more  from  excessive  ac- 
tion, than  from  a  higher  degree  of  inflammation  suddenly  ending 
in  gangrene. 

536.  When  proper  depletion  is  employed  early  in  this  form, 
it  is  sometimes  changed  into  a  regular  remittent,  and  sometimes 
ends  in  an  intermittent.*     The  same  remedies  must  be  employ- 
ed in  this,  as  in  the  other  forms;  but  with   these  differences; 
bleeding  and  purging  not  to  be  carried  to  the  same  extent,  though 
indispensably  necessary — a  much  smaller  quantity  of  blood  will 
diminish  the  force  of  the  circulation  ;  but  the  reaction  after  it,,  is 
more  prompt  and  certain.   Emetics  and  sweating  have  been  some- 
times advantageously  employed   after  due  depletion  about  the 
third  or  fourth  day,  where  the  stomach  would  reject  its  contents 
mixed  with  bile;  and  blisters  have  a  decidedly  good  effect  in  re- 
moving the  disposition  to  coma,  and  relieving  delirium  ;  they 
should  be  applied  first  to  the  legs,  and  then  a  large  one  to  the 
nape  of  the  neck,  and  extend  down  between  the  shoulders. 

537.  Should  the  inflammatory  stage  pass  over  without  an  at- 
tempt to  moderate  it,  the  system  becomes  so  prostrated  that  no- 
thing can  again    invigorate  it — it  must  be  left,  like  a  wreck, 
pretty  much  to  the  mercy  of  the  wind  and  waves  that  have 
overwhelmed  it — it  may  float  to  shore,  but  it  cannot  be  navi- 
gated there. 

538.  We  may,  however,  in  this,  as  well  as  the  two  other 
forms,  alleviate  certain  symptoms;  or  so  controul  them,  that  they 
shall  be  less  mischievous — the  nausea  may  sometimes  be  relieved 
by  the  Seltzer  or  soda-water,  or  by  the  effervescing  mixture — by 
lime-water  and  milk ;  and  in   the  last  stage,  even   where  black 
vomit  is  present,  the  spirit  of  turpentine  has  been  successfully 
employed — a  strong  infusion  of  cloves  has  also  been  used  with 
advantage  in  the  severe  vomitings  that  take  place  in  the  decline 
of  the  system — a  blister  over  the  stomach  may  also  be  useful.   A 
distressing  hiccough  sometimes  attends;  this  has  been  found  to 
yield  best  to  large  doses  of  camphor.    Should  a  weakening  diar- 
rhoea supervene,  the  chalk  julep  or  very  strong  allspice  tea  should 
be  given  until  it  be  sufficiently  restrained. 

539.  Porter  and  water  after  the  inflammatory  symptoms  have 

*  This  last  change  only  takes  place  in  the  later  part  of  the  season,  after  the 
weather  becomes  cooler.  That  is,  it  has  happened  pretty  late  in  the  fall,  to 
see  this  change;  but  whether  these  cases  were  genuine  cases  of  yellow  fever 
may  be  doubted.  For  when  this  disease  is  epidemic,  every  fever  in  the  vici- 
nity of  its  visitation  is  thought  to  be  yellow  fever;  yet  the  circumstance  is 
noted  by  most  modern  writers  upon  tropical  diseases. 


RUBEOLA,    OR    MEASLES.  171 

yielded  to  remedies  or  passed  away,  has  almost  always  been 
found  a  most  grateful  beverage,  as  well  as  being  very  often  suc- 
cessful in  quieting  nausea  or  arresting  vomiting. 

540.  We  may  here  remark  that,  as  the  season  advances  this 
disease  bears  more  bleeding  than  in  the  very  hot  weather;  or  in 
other  words,  the  phlogosis  of  the  stomach  is  less  rapid  in  its  pro- 
gress to  disorganization.  The  extreme  fatality  of  this  disease, 
together  with  the  popular  belief,  that  it  is  propagated  by  conta- 
gion, has  justly  rendered  it  a  terror,  as  well  as  a  scourge, 
wherever  it  may  present  itself.  Yet,  notwithstanding  its  great 
mortality,  it  does  not  appear  to  be  more  formidable  than  the 
fever  treated  at  the  London  Fever  Hospital,  if  Dr.  Tweedie's* 
tabular  exhibit,  be  correct.  He  says,  that  in  1829,  ending  on  the 
1st  Sept.  of  that  year,  five  hundred  and  twenty-one  patients  were 
admitted;  of  which,  four  hundred  and  forty-five  were  cured — 
three  turned  over  to  the  small-pox  hospital — and  seventy-three 
died.  Agreeably  to  this  statement,  one  in  every  seven  died; 
and  this  in  the  common  continued  form  of  fever;  but  when  this 
fever  was  complicated  with  pulmonic  inflammation,  "  about  one- 
third  died."  Now,  we  believe  that  in  no  one  instance  of  the 
epidemic  yellow  fever,  was  the  proportion  of  deaths  greater  than 
even  these  average  losses  of  the  London  Fever  Hospital. 


CHAPTER  II. 

RUBEOLA,  OR  MEASLES. 

541.  This  disease  occurs  for  the  most  part  in  winter  and  in 
the  spring;  at  least  its  appearance  is  much  more  frequent  at  these 
periods,  than  at  other  portions  of  the  year.     It  may  however 
prove  epidemic,  in  the  summer. 

542.  This  disease  is  evidently  influenced  by  the  state  of  the 
weather;  it  is  more  moderate  in  mild,  than  in  severe  weather. 

543.  It  is  the  opinion  of  some,  that  measles  is  regular  in  its 
recurrence  as  an  epidemic ;  the  interval  is  said  to  be  seven  years. 
Whether  this  is  rigidly  the  case,  we  are  not  prepared  from  pre- 
sent data  to  decide ;  it  is,  however,  rendered  probable,  that  there 
is  either  a  regular  return  at  this  period,  or  at  least,  an  approxi- 
mation to  it.     It  is  said  to  be  contagious ;  but  this  may  be  pretty 
fairly  disputed,  notwithstanding  the  imposing  experiments  of 

*  Clinical  Illustrations  of  Fever,  &c.     By  Alexander  Tweedie,  M.  D. 


172  RUBEOLA,    OR    MEASLES. 

Dr.  Home,  who  declared  he  propagated  the  disease  by  inocula- 
tion. An  Italian  physician,  (Speranza,)  declares  he  has  succeed- 
ed in  an  attempt  at  inoculation  by  puncturing  a  full  measle  with 
a  lancet,  and  inserting  the  blood  that  was  yielded  by  the  punc- 
ture ;  he  declares  he  was  successful  in  six  cases.  On  the  other 
hand,  Dr.  Chapman,  (MS.  Lectures,)  says,  upon  this  point,  that 
"experiments  of  this  nature  were  instituted  in  the  practice  of 
our  Dispensary  in  1801 ;  in  which  the  blood,  the  tears,  the  mu- 
cus of  the  nostrils,  bronchia,  the  eruptive  matter  in  the  cuti- 
cle properly  moistened,  were  all  tried,  and  without  success  in 
any  one  instance."* 

544.  Neither  is  it  settled  whether  the  constitution  can  be 
made  to  suffer  the  rubeolus  action  a  second  time;  evidence  is  so 
entirely  contradictory  on  this  point,  that  it  would  not  be  safe  to 
draw  a  positive  conclusion,  either  in  favour,  or  against  it.     One 
thing  we  may  however  safely  declare,  that  if  it  be  taken  a  second 
time,  it  is  contrary  to  the  ordinary  character  of  this  disease  ;t  or 
in  other  words,  it  is  but  an  exception  to  the  general  rule,  as  re- 
gards several  of  the  diseases  which  propagate  themselves  by  spe- 
cific contagion,  as  small-pox,  cow-pox,  hooping-cough,  chicken- 
pox,  &c.     For  it  is  now  well  ascertained,  that  exceptions  do 
occur;  we  have  ourselves  known  each  of  the  diseases  just  enume- 
rated, repeated  and  seemingly  so  unequivocally,  as  to  leave  no 
doubts  in  our  minds  upon  the  subject. 

545.  The  measles  are  ushered  in  like  other  febrile  affections, 
by  chilliness,  languor,  oppression,  heat,  and  thirst,  especially  the 
first  day;  these  terminate  in   a   perfectly   well-formed  fever. 
Sometimes  sickness,  and  even  vomiting  attend.J     The  fever  is 

*  Dr.  Tourtual,  a  Dutch  physician,  states  that  when  the  measles  were  epide- 
mic, all  the  children  that  were  under  treatment  with  sulphur  for  itch  escaped 
the  disease;  and  that  those  who  were  taking  sulphur  for  the  cure  of  hooping- 
cough  enjoyed  the  same  immunity.  Finally,  he  says  that  many  children  to 
whom  was  given  a  mixture  of  camphor  and  sulphur,  and  to  whom  these  medi- 
caments were  applied  by  friction,  were  not  attacked  with  measles,  while  those 
not  subjected  to  this  medication  were  affected. — Jlmer.  Journ.  of  Med.  Sciences 
for  May,  1832. 

f  There  is  a  variety  of  this  disease,  however,  which  affords  no  protection 
against  the  genuine  measles;  this  is  called  the  French  measles,  or  the  rubeola 
sine  catarrho.  Dr.  Gregory  says  this  is  "a  very  rare  variety,  and  only  inte- 
resting in  a  pathological  point  of  view."  We  have  had  several  opportunities 
to  see  this  form  of  measles.  Dr.  Hosack  witnessed  it  in  1813  in  New  York.  It 
has  never  required  any  active  treatment  as  far  as  we  have  observed. 

$  The  measles  of  this  season,  (early  in  1832,)  have  been  attended  with  more 
nausea  and  vomiting,  than  is  usual  in  this  disease.  The  disease,  as  far  as  I  have 
seen,  and  I  have  witnessed  many  cases,  has  been  remarkably  mild — the  pecto- 
ral symptoms  comparatively  light;  the  fever  slight,  and  the  eruption  less  abun- 
dant than  common.  It  may  however  be  proper  to  add,  that  the  fever  was  more 
protracted  than  ordinary,  but  before  the  eruption  would  make  its  appearance; 
it  continued  longer,  though  milder  than  it  is  wont  to  do  after  this  had  taken 
place. 


RUBEOLA,   OR    MEASLES.  173 

pretty  high  from  its  first  assault,  but  not  regularly  so;  as  it  oc- 
casionally seems  to  augment  for  two  or  three  days;  and  then  be- 
comes very  considerable  at  the  time  the  eruption  makes  its  appear- 
ance upon  the  skin,  which  usually  is  not  before  the  fourth  day.  We 
have  seen  the  eruption  take  place  with  but  very  little  fever. 
Cough,  a  little  hoarseness,  slight  sore  throat,  pain  in  the  chest, 
and  difficulty  of  breathing,  are  the  usual  attendants  upon  this 
disease.  The  eyes  are  particularly  affected;  they  are  always 
slightly  inflamed,  and  the  lids  a  little  swelled;  and  these  symp- 
toms are  attended  by  a  plentiful  secretion  of  scalding  tears.  Sy- 
denham  looks  upon  these  symptoms  as  marking  with  much  cer- 
tainty, the  approach  of  the  measles.  The  discharge  from  the 
nostrils  is  also  abundant;  and  sometimes  it  is  acrid.  Sneezing  is 
almost  a  never-failing  attendant  upon  this  complaint. 

546.  The  eruption  almost  always  occupies  the  face  and  neck 
before  it  is  observed  elsewhere ;  it,  however,  for  the  most  part 
spreads  itself  successively  over  the  whole  body.  But  should  this 
not  occur  strictly,  and  the  eruption  show  itself  in  "large  red 
spots,  not  rising  above  the  surface ;"  it  may,  nevertheless,  be  a 
genuine  measles.* 

547.  This  eruption  is  mostly  very  florid ;  and  it  retains  this 
colour  for  the  first  three  or  four  days ;  after  this  time  it  becomes 
brownish,  and  then  gradually  vanishes,  and  is  followed  by  a 
desquamation  of  the  cuticle.     "  These  red  spots  are  composed," 
agreeably  to  the  same  author,  "of  small  red  pimples  seated  near 
each  other,  and  rising  a  little  higher  than  the  surface  of  the  skin, 
so  that  they  may  be  felt  upon  pressing  them  lightly  with  the 
finger,  though  they  can  scarcely  be  seen."t 

548.  The  eruption  does  not  much  abate  the  severity  of  the 
fever ;  at  least  the  heat  of  the  skin  remains  equally  great ;  espe- 
cially that  of  the  head  and  neck,  both  of  which  have  a  look  of 
greater  fulness  than  natural.   Sometimes,  however,  an  abatement 
of  fever  may  be  observed  after  the  completion  of  the  eruption ; 
but  for  the  most  part  it  does  not  entirely  cease  until  the  cuticle  is 
cast  off.     The  vomiting  which  usually  accompanies,  or  ushers 
in  the  disease,  almost  always  ceases  at  this  period;  but  the  fever 
and  cough  seem  rather  to  augment,  and  is  very  frequently  ac- 
companied with  drowsiness. 

549.  We  have  said  cough  was  an  attendant  upon  this  com- 
plaint; indeed  it  may  be  said  to  be  of  never-failing  occurrence. 
It  is  in  the  commencement  dry>  frequent,  and  sometimes  pain- 
ful; but  as  the  fever  declines,  it  becomes  jnore  open,  and  often- 
times the  expectoration  is  even  great.     Pneumonic  symptoms 
very  frequently  attend  measles ;  and  sometimes  this  disease, 

*  Sydenham,  Vol.  I.  p.  257.  t Ibid- 


174  RUBEOLA,   OR    MEASLES. 

when  epidemic,  is  characterized  by  this  tendency.  We  remem- 
ber it  to  have  been  epidemic  early  in  the  spring  of  1785  or  1786, 
at  which  time  almost  every  case  was  marked  by  pneumonic 
symptoms  of  great  violence.  That  epidemic  was  of  difficult  ma- 
nagement; it  ran  its  course  with  unusual  rapidity,  and  not  un- 
frequently  terminated  in  death;  and  in  all  instances  almost,  the 
cough  was  severe,  obstinate,  and  of  very  long  duration.  Indeed, 
in  many  cases  it  yielded  but  to  the  genial  heat  of  advancing 
spring,  or  to  that  of  summer. 

550.  The  only  disease  with  which  measles  can  well  be  con- 
founded, is  scarlatina;  yet  it  is  pretty  easily  distinguished  from 
it  by  attending  to  the  characters  of  each.     The  sneezing,  the 
watery  eyes,  the  severe  cough,  the  pneumonic  tendencies,  all 
serve  to  distinguish  the  measles  from  scarlatina.     Besides,  in 
measles  there  is  less  swelling  in  the  skin ;  the  redness  is  not  so 
uniform,  nor  is  the  tone  of  colour  precisely  the  same.      In  scar- 
latina, the  tone  of  colour  on  the  skin  is  much  more  vivid  than 
in  measles,  and  seems  to  lay  beneath  the  cuticle — and  is  truly  a 
scarlet  colour.     In  measles  the  eruption  has  a  mixture  of  the 
modena  with  the  scarlet;  that  is,  it  has  a  shade  of  purple.     Be- 
sides, in  measles  there  is  a  little  roughness  to  be  perceived  if  the 
hand  be  slowly  passed  over  the  skin  that  is  occupied  by  erup- 
tion ;  which  is  not  the  case  generally,  indeed  very  rarely,  with 
scarlatina. 

551.  In  measles,  the  eyes  are  much  more  sensible  to  light,  and 
are  very  much  more  tearful  than  in  scarlatina;  nor  are  the  fauces 
so  much  affected  in  the  former,  as  in  the  latter  disease.    Indeed, 
we  have  seen  many  cases  of  genuine  measles,  without  the  throat 
being  at  all  affected,  which  rarely  happens  with  scarlatina.     In 
measles,  there  is  less  certainty  of  a  desquamation  of  the  skin; 
in  truth,  in  the  former,  it  is  more  a  branny  scrufthan  a  true  des- 
quamation. 

552.  As  regards  the  prognosis,  it  may  be  observed,  that  this 
disease  is  dangerous  in  proportion  as  the  head,  the  lungs,  and 
the  stomach  may  be  affected.     And  in  habits  disposed  to  con- 
sumption, it  is  always  bad,  at  least  it  is  always  to  be  feared. 

553.  Much  fever  without  a  corresponding  quantity  of  erup- 
tion, or  the  latter  making  its  appearance  reluctantly,  or  of  a  pale 
or  livid  colour,  is  always  a  bad  sign;  and  is  usually  attributed  to 
a  want  of  vigour  in  the  constitution;  but  this  is  not  so  without 
exception,  or  perhaps  it  is  very  rarely  the  case.     We  shall  again 
advert  to  this  condition  presently. 

554.  The  abrupt  disappearance  of  the  eruption,  or  its  becom- 
ing pale,  is  unfavourable;  especially  on  the  first  day  or  two  of 
the  eruption ;  or  if  it  be  attended  by  severe  vomiting,  a  great 
tenderness  of  the  epigastrium,  or  a  diarrhoea.     Should  none  of 


RUBE  OLA,    OR    MEASLES.  175 

these  untoward  symptoms  take  place,  the  case  will  most  proba- 
bly terminate  propitiously.  But  we  must  be  upon  our  guard 
not  to  mistake  the  ordinary  progress  of  the  disease  for  a  retro- 
cession of  the  eruption.  For,  as  the  disease  usually  runs  its 
course  in  eight  or  nine  days,  the  eruption  is  observed  to  disap- 
pear pretty  generally  at  this  time;  and  by  the  ignorant,  is  sup- 
posed to  have  taken  place  much  too  soon,  and  with  a  view  of 
maintaining  it  upon  the  skin,  stimulating  drinks  and  medicine 
are  freely  exhibited;  the  patient  is  covered  warm  from  head  to 
foot,  and  every  avenue  for  air  is  carefully  shut  up.  In  conse- 
quence of  such  treatment,  the  patient  is  thrown  suddenly  into 
imminent  danger;  fever  is  rekindled,  cough  and  other  pneumonic 
symptoms  increase,  and  the  eruption  assumes  a  livid  or  black 
hue,  and  if  not  relieved  soon  by  proper  treatment,  the  patient 
quickly  dies. 

555.  Death,  when  it  happens,  however,  takes  place  in  measles 
at  different,  periods  in  the  progress  of  the  disease,  which  pro- 
duces a  difference  in  the  phenomena  observable  in  examinations; 
thus  it  has  been  known  to  prove  fatal  as  early  as  the  fourth  day. 
When  this  event  takes  place  so  early,  it  is  generally  attributed 
to  the  "  striking  in"  of  the  eruption;   but  this  is  not  the  case, 
were  we  to  adopt  even  the  popular  language  upon  this  subject; 
for  when  a  disease  leaves  the  skin,  or  more  properly  speaking, 
when  it  is  no  longer  maintained  there,  it  is  not  because  it  has 
changed  its  seat,  but  because  some  portion  of  the  mucous  mem- 
brane may  be  too  powerfully  affected  by  an  efflorescence  similar 
in  its  nature  to  that  which  occupied  the  skin. 

556.  In  this  case,  the  peculiar  action,  or  inflammation  consti- 
tuting measles,  so  far  transcends  its  ordinary  degree,  as  to  de- 
stroy its  peculiarity  of  action  in  either  the  mucous  membrane  of 
the  bronchia,  or  of  the  stomach,  or  intestines;  and  consequently 
the  peculiar  sympathy  of  the  skin  which  gave  rise  to  the  erup- 
tion upon  its  surface,  could  no  longer  be  maintained;  because 
the  specific  action  on  other  parts,  and  from  which  the  sympathy 
arose,  no  longer  existed,  in  consequence  of  the  inordinate  or 
altered  action  in  the  original  seat  of  irritation.     The  same  thing 
occurs  in  variola. 

557.  In  these  cases,  when  pneumonic  symptoms  are  severe, 
it  would  seem  that  the  mucous  membrane  of  the  trachea,  bron- 
chia, and  air  cells,  are  found   highly  inflamed,  and  not  unfre- 
quently  filled  with  mucous  and  bloody  serurn;  this  is  especially 
the  case  when  the  patient  dies  in  the  early  stage  of  the  disease. 
In  the  later  stages,  ulcerations  of  the  parts  have  been  observed. 
In  measles,  the  inflammation  of  the  bronchial  membrane  has  a 
strong  resemblance  to  the  efflorescence  on  the  skin;  that  is,  it 
exists  in  detached  semicircles. 


176  RUBEOLA,  OR  MEASLES. 

558.  Measles  seems  to  be  more  decidedly  attended  by  that 
condition  of  the  system  called  inflammatory,  than  almost  any 
other  of  the  eruptive  diseases;  or,  in  other  words,  its  epidemic 
character  is  more  frequently  inflammatory  than  otherwise.  There 
are  exceptions  of  course,  imposed  by  constitution,  and  season  of 
the  year;  but  above  all,  by  the  epidemic  peculiarity  of  the  at- 
mosphere; hence  it  is  sometimes  highly  inflammatory,  requiring 
the  most  active  evacuations  and  extensive  depletion  by  blood- 
letting, &c.  to  keep  it  in  controul.  While  again  it  may  have  a 
highly  malignant  character,  and  for  the  relief  of  which  we  must 
have  recourse  to  the  opposite  means. 

559.  Sydenham,  however,  did  not  order  bleeding  in  the  be- 
ginning, nor  even  at  the  height  of  the  disease,  though  so  fond  of 
this  remedy,  under  almost  every  circumstance  at  other  periods 
of  the  disease. 

560.  This,  in  our  opinion,   shows  how  discriminating  this 
great  man  was — for  he  would  not  prescribe  for  the  name  of  the 
disease;  the  epidemic  of  1670  does  not  appear  to  have  been 
highly  inflammatory ;  as  a  strict  antiphlogistic  regimen  with  de- 
mulcents, he  informs  us,  "  seldom  failed  to  cure  the  disease." 

561.  Therefore,  regard  must  be  had  to    the    character    the 
measles  assumes ;  and  they  must  be  treated  accordingly — if  fever 
be  high,  cough  and  oppression  severe,  blood  should   be  drawn 
immediately,  though  these  symptoms  occur  at  rather  an  uncom- 
mon period  of  the  disease,  namely,  in  its  forming  stage;  for  such 
changes  may  be  imposed  upon  the  character  of  measles  by  some 
constitutions  of  the  air,  or  other  cause,  as  render  this  at  times 
absolutely  necessary. 

562.  From  this  view   of  the    constitutional    differences  of 
measles,  it  will  at  once  appear,  that  its  treatment  must  vary  ac- 
cording to  its  specific  character ;  or  its  form  may  be  so  mild  as 
to  require  no  medical  treatment.     We  have  not  been  under  the 
necessity  of  bleeding  but  twice  this   season    for  this  disease, 
though  we  have  prescribed  for  more  than  one  hundred  up  to  this 
time,  (April,  1829,)  so  mild  has  the  character  of  the  measles 
been.* 

563.  In  attacks  of  severity,  especially  where  much  cough, 
oppression,  or  pain  in  the  chest  attend,  the  first  remedy  we  can 
probably  use  with  advantage,  is  blood-letting;  the  quantity  must 
be  regulated  by  the  age  of  the  child,  the  force  of  disease,  and  the 
immediate  effect  of  the  remedy.   It  must  however,  be  remarked, 
that  in  measles,  though  we  are  obliged  to  repeat  this  operation  ; 
it  rareiy  requires  large  quantities  to  be  drawn  at  a  time;  and  the 

*  This  season,  (1832,)  we  have  not  had  occasion  to  draw  blood  but  once, 
and  in  this  instance  the  necessity  of  bleeding  was  created  by  excessive  expo-, 
sure  to  cold  during  the  febrile  stage  of  the  disease. 


RUBEOLA,   OR    MEASLES.  177 

repetition  must  be  governed  by  the  state  of  the  pulse,  and  con- 
tinuance of  the  violent  symptoms. 

564.  Much  objection  is  made  to  bleeding  in  the  measles  by 
some;  this  fear  is  without  foundation  in  most  cases  of  this  com- 
plaint; for  as  a  general  rule  we  may  declare,  there  are  few  dis- 
eases which  more  decidedly  require  this  remedy;  for  there  are 
few  in  which  the  lungs  are  so  seriously  implicated.     Under  the 
best  management,  it  is  but  too  apt  to  leave  a  troublesome  and 
obstinate  cough;  but  this  is  sure  to  be  the  case,  if  not  augmented, 
if  blood-letting  have  not  been  performed  where  the  case  required 
it;  and  we  may  most  safely  add,  that  this  but  too  frequently  hap- 
pens, since  this  operation  is  but  too  often  proscribed.  It  is  true,  if 
we  are  to  believe  authors,  that  now  and  then,  the  character  of  this 
epidemic  is  such  as  to  forbid  in  almost  every  case,  blood-letting; 
but  this  is  only  the  exception  to  the  rule.*  And  we  are  disposed 
to  believe,  that  these  exceptions  in  many  instances  were  imagi- 
nary, or  rather  that  the  true  mode  of  treatment  has  been  ill  un- 
derstood.    Sydenham  appears  to   be  authority  for  this  belief; 
for  we  are  of  opinion,  that  few  would  have  bled  under  the  cir- 
cumstances, he  declares  he  found  the  maid  servant,  of  "  lady 
Anne  Harrington,  who  had  the  measles,  joined  with  fever,  diffi- 
culty of  breathing, purple  spots  over  the  whole  body  and  many 
other  dangerous  symptoms,  all  of  which"  says  he  "I  ascribed 
to  the  hot  regimen  and  medicines  which  had  been  too  freely  used. 
I  directed  bleeding  in  the  arm,  and  prescribed  a  cooling  pectoral 
ptisan  to  be  taken  often,  by  means  of  which,  and  a  more  cooling 
regimen,  the  purple  spots  and  all  the  other  symptoms  went  off 
by  degrees."  p.  264.  Vol.  I. 

565.  We  had  an  opportunity  in  our  present  epidemic^  (March, 
1828,)  of  witnessing  the  advantage  of  this  mode  of  treatment 
in  a  young  woman  of  eighteen.    She  was  attacked  with  measles, 
which  made  their  appearance  with  great  reluctance;  on  the  day 
before  they  began  to  show  themselves,  she  had  been  taken  with 
her  menstrual  discharge — but  the  moment  the  measles  began  to 
appear  her  catamenia  ceased.     She  now  become  very  much  op- 
pressed ;    breathing  laborious;    cough   almost   incessant ;  com- 
plained much  of  her  head;  was  slightly  delirious;  tongue  loaded 
and  very  white ;  breath  offensive ;  could  not  lie  down,  without 
a  sense  of  suffocation;  measles  not  abundant,  but  very  dark- 
coloured,  with  a  frequent,  rapid  pulse.     She  was  bled  fourteen 
ounces,  and  purged  with  salts  and  magnesia;  directed  to  drink 

*  In  the  measles  of  1832,  the  character  of  the  epidemic  did  not  forbid  the 
use  of  the  lancet, — the  mildness  of  the  disease  only  rendered  this  remedy  un- 
necessary. 

23 


178  RUBEOLA,    OR    MEASLES. 

very  freely  of  barley  water,  and  to  be  allowed  nothing  beside. 
On  our  visit  the  following  morning,  we  foundftherjrelieved  of  all 
her  unpleasant  symptoms,  and  the  measles  in  plentiful  quantity, 
and  of  a  healthy  appearance ;  cough  nearly  gone;  free  from  all 
pain,  and  a  plentiful  flow  of  the  catamenia.  She  recovered  ra- 
pidly. 

566.  There  are  few  diseases  which  put  on  a  menacing  appear- . 
ance,  that  are  worse  treated  than  measles ;  especially  when  the 
eruption  is  about  to  take  place.     Should  this  fail  to  be  as  rapid 
in  its  evolution,  or  as  extensive  in  its  diffusion,  as  meets  the  views 
of  some  old  woman,  or  an  ignorant  nurse,  the  disease  is  almost 
sure  to  be  converted,  by  stimulating  applications  into  one  of 
danger,  however  simple  it  might  have  proved,  had  its  course  and 
tendency,  been  undisturbed.     With  a  view  to  promote  the  erup- 
tion, heating  teas  of  various  kinds,  and  even  liquors  are  given, 
to  the  certain  injury,  if  not  to  the  absolute  destruction  of  the 
patient — this  conduct  cannot  be  too  strongly  reprobated,  or  too 
peremptorily  forbidden. 

567.  The  same  error  is  committed  almost  always,  where  the 
eruption  seems  tardy,  or  reluctant  in  its  appearance:  for  it  is 
wrongly  imagined,  that  this  can  only  proceed  from  a  want  of 
force  in  the  system;  and  that  the  efforts  of  nature  must  be  second- 
ed by  heating  teas  of  various  kinds,  wine  whey,  milk  punch,  &c. 
when  nothing  could  have  relieved  the  oppressed  system,  but 
blood-letting,  and  other  evacuating  'remedies.     And  hence  we 
are  disposed  to  believe,  this  disease  so  frequently  proves  fatal. 
For  if  the  pathology  of  the  measles,  now  so  generally  assumed, 
be  true,  the  cause  of  the  eruption  not  appearing  upon  the  skin 
may  be  owing  to  the  intensity  of  gastric  irritation,  or  inflamma- 
tion, as  we  have  already  attempted  to  explain,  which  requires 
the  loss  of  blood  from  the  system  at  large,  or  from  over  the  re- 
gion of  the  stomach,  by  leeching  or  cupping. 

568.  In  aid  of  the  bleeding  we  should  employ  calomel,  so  as 
to  freely  discharge  the  bowels,  without  urging  them  to  brisk 
purging.     And  also  to  prescribe  a  strict  antiphlogistic  regimen;* 
together  with  demulcent  drinks,  as  flaxseed  tea,  barley  water, 
bran  tea,  gum  Arabic  water,  &c.  It  may  also  become  necessary, 
where  the  pneumonic  symptoms  continue  after  bleeding,  to  draw 
blood  from  near  the  seat  of  the  local  affection  by  cupping;  and 
this  to  be  followed  by  a  blister. 

569.  When  the  system  is  sufficiently  reduced  to  bear  opium 
in  some  form  or  other,  it  should  be  administered,  so  as  to  ap- 

*  We  have  already  defined  what  we  wish  to  be  understood  when  we  pre- 
scribe a  strict  "  antiphlogistic  regimen."    See  pars.  207  to  217- 


RUBEOLA,    OR    MEASLES.  179 

pease  the  cough,  which  but  too  often  is  very  distressing:*  or 
we  may  give  the  denarcotized  laudanum,  the  "  black  drop"  or 
the  acetated  tincture  of  opium.  Either  of  these  should  be  ad- 
niinistered  at  night,  in  combination  with  antimonial  wine,  in 
suitable  doses — for  instance ;  a  child  from  two  to  four  years  of 
age  may  take  three  or  four  drops  of  the  black  drop,  with  ten  of 
antimonial  wine  at  bed  time,  or  double  this  quantity  of  the  lau- 
danum ;  and  should  this  not  relieve  the  cough,  and  appease  the 
inquietude  in  two  hours,  it  may  be  repeated — for  children  more 
advanced,  we  must  increase  the  dose  a  little.  But  a  few  trials 
of  rather  an  under-dose  will  soon  lead  to  the  knowledge  of  the 
required  quantity.  For  children  under  two  years  old,  we  have 
found  the  syrup  of  poppies  to  answer  admirably.  This  may  not 
only  be  given  at  night,  but  also  in  the  day,  and  may  most  ad- 
vantageously be  repeated,  as  the  necessity  arises ;  from  a  small 
tea,  to  a  pap-spoonful  will  be  sufficient  for  a  child  from  six 
months  to  two  years  old. 

570.  Should  the  character  of  this  disease  be  typhoid,!  the 
lancet  must  be  sparingly  used,  and  perhaps  not  at  all,  except  in 
the  beginning;  but  when  there  is  great  oppression,  or  pain  in  the 
chest,  with  much  cough,  cupping  will  be  found  both  necessary 
and  advantageous — this  must  for  the  most  part  be  followed  by 
blistering. 

571.  Emetics  are  also  useful  in  this  species  of  measles,  and 
should  be  employed  where  there  is  great  accumulation  of  phlegm, 
and  the  expectoration  but  inconsiderable.    Mercurial  purges  are 
also  to  be  given,  even  to  plentiful  purging.  It  is  occasionally  use- 
ful to  employ  the  warm  but  not  a  hot  bath;  especially  where  the 

*  We  have  found  the  following  mixture  answer  admirably  well: — 


Sperm,  ceti 
Vitel  ovi 
Pulv.  g.  Arab. 
Elix.  paregor. 
Vin.  antim.     - 
Sacch.  alb. 
Aqua  font. 


3'J. 

3; 

3'J- 


Take  of  spermaceti      -  2  drachms. 
Yelk  of  an  egg    -  1 
Powdered  gum  Ara- 
bic 2  drachms. 
Paregoric  elixir   -  6  drachms. 
Antimonial  wine  4  drachms. 
White  sugar        -  3  drachms. 


M.  I  Water  6  ounces. 

Mix. 

Of  this  a  table-spoonful  is  to  be  given  every  two  or  three  hours,  until  the  cough 
is  relieved.  This  dose  is  calculated  for  an  adult — for  children  the  quantity 
must  be  proportional.  Nofc. — To  make  this  mixture,  the  spermaceti  and  the 
yelk  of  the  egg  must  be  first  rubbed  together  until  well  incorporated — add 
then  the  gum  Arabic  and  the  other  ingredients  in  succession;  when  these 
are  well  mixed  together,  let  the  water  be  added  gradually — keep  it  in  a  cool 
place. 

f  We  are  of  opinion  that  too  much  care  cannot  be  taken,  not  to  confound 
what  is  termed  a  typhoid  condition,  with  an  existing  inflammatory  state  of  the 
system;  witness  the  case  related  by  Sydenham,  par.  564. 


180  RUBEOLA,    OR    MEASLES. 

character  of  the  eruption  is  not  sufficiently  healthy ;  looking  either 
too^pale  or'livid,  provided  the  pulse  is  not  so  active  as  to  require 
bleeding. 

572.  Should  the  appearance  of  exhaustion  supervene,  we  must 
have  recourse  to  the  diffusible  stimuli,  as  wine  whey,  and  the 
volatile  alkali;  and  these  may  be  aided  by  blisters  to  the  extre- 
mities, or  by  sinapisms  to  the  soles  of  the  feet. 

573.  It  is  of  much  consequence,  throughout  the  whole  course 
of  this  disease,  that  the  temperature  of  the  air  of  the  patient's 
chamber  should  be  regulated,  and  not  made  to  exceed  sixty-four 
or  five;  sixty  perhaps  would  be  the  best  standard.     This  tempe- 
rature would  be  warmer  than  would  be  useful  for  small-pox; 
measles  however  requires  this;  but  it  is  never  proper  to  keep 
the  patient  hot,  either  by  a  heated  atmosphere  or  bed-clothes. 
The  constant  disposition  to  cough   will  readily  explain,  why 
measles  requires  a  higher  temperature  than  small-pox.  Dr.  Gre- 
gory observes  that  "  it  is  well  ascertained,  that  these,  (the  symp- 
toms of  thoracic  inflammation,)  are  often  aggravated  by  a  free 
exposure  of  the  body  to  cold,  either  during  or  previous  to  the 
eruption ;  and  some  have  remarked,  that  this  aggravation  of  the 
catarrhal   symptoms,  is  occasionally   attended  by  a  recession  of 
the  eruption ;  moderate  warmth  therefore,  is  on  all  accounts  acl- 
viseable  in  measles." 

574.  Measles  but  too  frequently  leave   disagreeable  conse- 
quences behind  them  ;  especially  cough.     This  secondary  or  su- 
pervening cough,  is  too  often  neglected,  owing  to  the  belief  that 
more  or  less  must  necessarily  follow  this  disease.     This  affec- 
tion takes  place  after  the  patient  has  gone  through  the  eruptive 
stage ;  and  dissection  reveals,  that  it  is  owing  to  an  inflamma- 
tion having  attacked  the  mucous  membrane  of  the  bronchia. 
This  complaint  comes  on  sometimes  so  insidiously,  that  it  makes 
a  fatal  progress  before  danger  is  apprehended ;  we  should  there- 
fore never  trust  a  patient  to  nature  and  time,  in  whom  a  consi- 
derable difficulty  of  breathing  exists,  accompanied  by  a  wheez- 
ing; nor  must  we  be  deceived,  because  the  cough  is  not  severe; 
for  in  some  of  the  worst  cases,  the  cough  is  not  always  violent. 

575.  The  cough  is  generally  dry  and  fatiguing;  and  comes 
on  by  paroxysms.     The  pulse  is  hard  for  the  most  part,  and 
always  frequent;  great  thirst,  tongue  loaded,  bowels  constipated 
and  a  hot  skin.     This  is  a  state  of  great  danger ;  the  bronchia 
are  soon  filled  with  mucus,  and  the  patient  dies  from  the  failure 
of  the  due  oxygenation  of  the  blood.     This  complaint  must  be 
treated  as  an  acute  bronchitis. 

576.  A  deranged  state  of  the  bowels  may  also  follow,  parti- 
cularly if  the  disease  has  been  ill-managed,  by  over-stimulation, 
exposure,  or  improper  diet,  too  soon  after  the  fever  has  passed 


SCARLET    FEVER.  181 

away.  On  this  account  a  patient  recovering  from  this  disease, 
must  never  be  exposed  to  cold,  or  damp;  should  be  confined  for 
some  time  to  a  milk  and  vegetable  diet;  and  made  to  wear  in 
cold,  or  cool  weather,  flannel  next  the  skin. 

577.  Sydenham informsus,thatthediarrho3afollowingmeasles, 
has  always  been  best  relieved,  by  blood-letting. 


CHAPTER  III. 

OF  SCARLATINA,  OR  SCARLET  FEVER. 

578.  This  is  so  denominated,  on  account  of  the  peculiarly 
florid  appearance  of  the  skin,  by  which  it  is  accompanied.     In 
some  one  of  the  several  forms,  which  we  shall  presently  see  it 
puts  on,  this  complaint  has,  from^  an  early  period,  occupied  no 
inconsiderable  share  of  attention.     It  is  frequent  in  its  occur- 
rence, extensive  in  its  prevalence,  and,  at  times,  exceedingly 
fatal  in  its  terminations.  The  complaint  prevails  more  in  winter 
and  spring,  than  in  summer  or  autumn;  attacking  children,  in 
preference  to  those  who  are  more  advanced  in  years.*     By  the 
nosological  writers,  it  is  divided  into  three  forms ;  which  are  to 
be  regarded,  however,  as  nothing  more  than  the  same  disease, 
marked  by  different  degrees  of  violence: — the  scarlatina  sim- 
plex— scarlatina   anginosa — and   scarlatina  maligna.     To 
many,  the  latter  is  more  familiar  under  the  name  of  the  malig- 
nant, or  putrid  sore  throat  A 

579.  By  scarlatina  simplex,  is  to  be  understood,  the  simple 
constitutional  disease,  without  any  morbid  affection  of  the  throat. 
By  scarlatina  anginosa,  a  higher  degree  of  the  same  complaint 
• — the  throat  being  at  the  same  time  inflamed  and  swollen.     By 
scarlatina  maligna,  the  same  disease,  in  still  greater  violence 
— the  throat  being  more  violently  affected,  and  the  symptoms 
malignant. 

580.  It  is  unnecessary  to  enter  into  an  elaborate  discussion,  to 
establish  the  identity  of  the  diseases. 

581.  Like  most  other  fevers,  scarlatina  commences  with  chil- 
liness, fulness  of  the  head,  and  lassitude;  to  which  succeed,  pros- 
tration of  strength,  which  at  times  is  very  great;  and  nausea,  or 
vomiting.     The  surface  soon  becomes  florid,  and  hot ;  and  on 

*  Sir  Gilbert  Blane  says,  that  he  never  saw  a  person  turned  of  forty,  affected 
by  it. 

•j-  Dr.  Bateman  does  not  call  this  form  of  the  disease  scarlatina,  though  he 
treats  of  it  under  this  head. 


182  SCARLET    FEVER. 

examining  the  throat,  it  will  sometimes  be  found  inflamed;  and 
the  same  red  appearance  extends  to  the  tongue.*  There  is  often 
at  this  time,  more  or  less  catarrhal  affection ;  the  head  suffers  se- 
vere pain,  particularly  about  the  frontal  sinuses;  and  with  which 
is  sometimes  associated,  a  disturbance  of  the  intellectual  faculties. 
The  degree  of  these  symptoms,  indicates  with  sufficient  exact- 
ness, the  strength  and  character  of  the  forming  disease.  Being 
very  slight,  the  complaint  will  be  simplex;  if  less  so,  the  angi- 
nosa;  and  where  they  are  severe  and  threatening,  the  maligna. 
582.  In  the  worst  variety  of  scarlatina  maligna,  the  com- 
mencing symptoms  are  alarmingly  violent.  The  attack  is,  for 
the  most  part  sudden;  the  patient  becomes  pale,  sick,  and  faint; 
the  head  giddy,  heavy,  and  confused,  rather  than  severely  pain- 
ed ;  the  oppression  about  the  prsecordia,  is  extreme ;  the  heart 
palpitates,  and  the  stomach  suffers  great  uneasiness,  though  there 
is  no  vomiting — this  organ  being  probably  prostrated  below  the 
power  of  reaction.  The  face  is  pale,  or  livid;  the  eyes  exhibit  a 
glairy  appearance,  and  are  marked  by  a  fatuitous  or  inebriated 
expression.  "A  remarkable  tumefaction  of  the  fingers  some- 
times takes  place,  which,  with  the  erysipelatous  tinge  they  soon 
acquire,  is  often  of  itself  sufficient  to  characterize  the  disease." 
Gregory.  — In  a  word,  the  brain  is  generally  severely  affected ; 
and  the  character  of  the  eruption  is  also  somewhat  different — 
that  is,  it  appears  in  more  irregular  patches,  and  the  tone  of  co- 
lour of  the  efflorescence,  is  less  brilliant,  or  even  sometimes 
dusky ;  it  is  also  wont  to  disappear  and  reappear  at  uncertain  in- 
tervals. The  temperature  of  the  skin,  is  also  lower  than  in  the 
other  varieties,  often  indeed  not  above  the  natural  standard. 
Diarrhoea  sometimes  attend  this  form  of  scarlatina.  The  secre- 
tion from  the  nose,  and  other  portions  of  the  mucous  membrane, 
is  oftentimes  so  acrid  as  to  excoriate.  The  throat  and  larynx, 
nay  even  the  bronchi,  yield  an  acrimonious  secretion — the  paro- 
tid and  submaxillary  glands,  swell  from  inflammation,  and  even 
suppurate.  This  form  of  scarlatina  sometimes  terminates  fatally 
on  the  third  or  fourth  day;  it  is  however,  not  so  common  by  any 
means  as  the  other  species,  t 

•  This  last  presents  a  very  peculiar  aspect.  Through  the  fur  with  which  it 
is  covered,  the  elongated  papillae  project  their  points,  and  are  of  intensely 
deep  scarlet  hue. 

f  Dr.  Tweedie  says  that  "  in  the  fatal  cases,  the  appearance  on  dissection 
were  not  always  sufficient  to  explain  the  cause  of  death,  which  in  such  in- 
stances seemed  more  the  result  of  a  specific  poison  operating  on  the  brain  and 
mucous  membranes.  In  some,  the  brain  showed  marks  of  vascularity  and  effu- 
sion; in  others  the  mucous  membrane  of  the  larynx,  near  the  arytenoid  carti- 
lages, was  destroyed  by  ulceraLion,  and  the  membrane  of  the  trachea  and 
bronchi  was  in  several  excessively  inflamed.  In  one  or  two,  the  mucous  mem- 
brane of  the  intestines  was  inflamed;  in  one  instance  it  had  passed  into  ulcera- 
tion."  p.  203. 


SCARLET    FEVER.  183 

583.  On  the  second  or  third  day  from  the  commencement  of 
the  disease,  the  febrile  symptoms  are  considerable;  the  skin  be- 
comes morbidly  sensible  to  the  touch,  and  begins  to  be  covered 
with  an  efflorescence,  or  florid  eruption.*  About  the  same  time, 
a  degree  of  redness  and  swelling  appears  in  the  fauces.  The  skin 
is  excessively  hot;  more  so  perhaps  than  in  any  other  form  of 
febrile  disease.     The  pulse  is  also  very  frequent,  rarely  being 
under  one  hundred  and  twenty  strokes  in  a  minute. 

584.  The  reaction  of  the  system  being  now  completely  deve- 
loped, the  pulse  exhibits  the  character  which  belongs  to  the  exist- 
ing form  of  the  disease — preternaturally  frequent,  quick,  and 
active,  though  still  moderate,  if  the  disease  be  simple — more 
frequent,  irritated,  and  tense,  if  it  be  anginose — of  greater  fre- 
quency still,  but  not  so  full,  resisting,  and  firm,  if  it  be  malig- 
nant.    The  temperature  of  the  body,  the  thirst,  the  scurf  on 
the  tongue,  are  also  graduated  in  the  same  way;  each  symptom 
increasing  in  intensity,  according  to  the  augmented  violence  of 
the  case. 

585.  The  eruption  assumes,  at  times,  the  form  of  red  points, 
though  generally,  that  of  red  patches,  which  spread  and  unite, 
so  as  to  cover  the  whole  surface.  It  appears  first  on  the  face  and 
neck ;  and  in  the  course  of  a  short  time,  spreads  gradually  to  the 
lower  extremities.     The  redness  is  often  considerable  about  the 
loins,  and  the  bendings  of  the  joints,  and  on  the  hands,  and  ends 
of  the  fingers,  which  feel  stiff  and  swollen.    The  eruption  is  not 
very  regular,  either  as  to  the  time  of  its  appearance,  its  steadi- 
ness, or  its  duration.     It  usually  continues  about  four  days,  and 
goes  off  with  desquamation  of  the  cuticle.     As  the  disease  pro- 
ceeds, the  neck  and  lower  jaw  grow  stiff,  the  tonsils  swell,  and 
become  marked  with  specks,  which  degenerate  into  ulcers,  co- 
vered with  superficial,  ash-coloured  sloughs.    These  sloughs,  in 
favourable  cases,  separate  and  come  off,  about  the  eighth  or  tenth 
day,  when  the  ulcers  underneath  are  fresh,  and  florid,  and  heal 
kindly.     The  fever,  at  the  same  time,  gradually  abates,  and  a 
great  amendment  becomes  apparent.     We  may  also  add,  that 
metastasis  to  the  joints  occasionally  takes  place. 

586.  But,  in  the  more  malignant  cases,  the  course  of  the  dis- 
ease is  very  different.     The  sloughs  on  the  tonsils  grow  fouler; 
and  the  discharge  from  them,  and  the  nostrils  becomes  exceed- 
ingly acrid.     The  mouth  assumes  a  dark  colour,  and  is  often 
encrusted  with  a  black  or  brown  fur.     The  breath  is  extremely 
offensive,  a  tenacious  mucous  secretion  infests  the  fauces.     The 
eyes  and  nostrils  furnish  an  acrid  serum.     Haemorrhagies  some- 

*  The  tone  of  colour  is  said  to  be  that  of  a  boiled  lobster. 


184  SCARLET    FEVER. 

times  take  place  from  these  parts,  as  also  from  the  bowels;  diar- 
rhoea of  a  severe  kind  is  often  found  present ;  so  also  delirium  or 
coma.  If  the  throat  be  examined,  it  will  be  found  studded  with 
more  or  less  sloughs,  with  dark  or  livid  bases.  The  parotids  are 
swelled  and  tender  to  the  touch.  Painful  induration  of  the  glands 
of  the  neck,  which  sometimes  terminate  in  large  suppurating 
abscesses;  tenesmus,  and  diarrhoea;  which  speedily  sink  the  pa- 
tient, if  not  early  removed. 

587.  This  is  reputed  to  be  a  contagious  disease.  On  this  point, 
however,  the  evidence,  to  say  the  least,  is  equivocal.   The  facts 
connected  with  the  spreading  of  scarlatina,  seem  to  be  perfectly 
explicable,  on  the  ground  of  its  being  epidemic,  and  not  conta- 
gious.* In  this  country  the  belief  that  it  is  a  contagious  disease, 
is  by  no  means  so  general  as  it  is  in  Europe,  and  especially  as  it 
is  in  Great  Britain.     I  have  never  seen  so  far,  any  decided  proof, 
that  it  has  communicated  itself  in  any  one  instance.  On  the  con- 
trary, I  am  strongly  disposed  to  doubt  its  contagious  quality.    I 
attended  a  child  with  scarlatina  anginosa,  in  a  family  of  eight 
children ;  the  child  that  was  ill  was  constantly  surrounded  by 
the  well  children,  yet  not  one  of  these  sickened  afterwards  with 
this  disease.     The  same  thing  precisely  occurred  in  my  own 
family;  besides  many  less  remarkable  instances.     Gregory  says 
"the  slowness  of  its  diffusion  is  one  of  the  most  remarkable  cir- 
cumstances in  its  history."  Vol.  I.  p.  237. 

588.  As  regards  the  prognosis,  it  is  unfavourable  in  proportion 
to  the  malignant  character  of  the  disease.   Thus  great  prostration 
of  strength  ;  delirium  ;  or  coma  ;  extreme  restlessness ;  a  distilla- 
tion of  very  acrid  sanies  from  the  nose ;  a  purple  or  livid  appear- 
ance of  the  fauces,  without  tumefaction,  interspersed  with  white 
specks,  or  dark  sloughs,  attended  by  diarrhoea  of  acrid  matter; 
and  above  all,  a  change  of  the  efflorescence  to  a  mahogany  colour, 
are  mortal,  or  extremely  alarming  symptoms.    The  termination 
of  this  disease  is  sometimes  exceedingly  abrupt,  and  unexpected. 
We  have  known  death  to  take  place,  in  several  instances,  and 
this  most  suddenly,  where  every  hope  was  entertained  of  reco- 

*  The  weight  of  European  authority  is  perhaps  against  us;  and  in  actual 
practice,  it  will  be  safest  to  act  under  such  a  conviction.  We  are  indeed  told, 
that  the  power  of  infecting  endures  for  a  very  considerable  time— certainly  for 
a  week  or  two  after  the  cessation  of  the  efflorescence,  and  probably  as  long  as 
the  desquamation  of  the  cuticle  lasts.  Persons  who  have  been  exposed  to  the 
contagion,  have  the  disease,  it  is  said,  to  break  out  on  the  fifth  or  sixth  day. 
But  notwithstanding  the  apparent  admission,  "that  the  weight  of  European 
authority  is  against  us,"  it  does  not  appear  that  the  belief,  that  scarlatina  is 
propagated  by  contagion  is  universal  even  in  London,  or  one  of  the  regulations 
of  the  Fever  Hospital,  is  very  unwise,  as  we  are  informed  by  Dr.  Tweedie, 
that  "of  the  eruptive  fevers,  cases  of  scarlatina  alone  are  admissible." — Illus- 
trations of  Fever,  p.  25. 


SCARLET    FEVER.  185 

very,*  but  a  short  time  before.  The  favourable  signs  in  scarlet 
fever  are,  the  patient  surviving  the  ninth  day,  without  any  de- 
cided mortal  symptoms ;  the  intensity  of  the  colour  of  the  skin 
abating  gradually ;  desquamation  of  the  cuticle,  and  the  depar- 
ture of  the  swelling  from  every  portion  of  the  body  to  which  it 
had  extended ;  the  separation  of  the  sloughs,  with  a  healthy  ap- 
pearance of  the  parts  from  which  they  separated  ;  pulse  becoming 
slower  and  less  irritated ;  heat  abating;  urine  depositing  a  lateri- 
tious  sediment,  refreshing  sleep,  and  return  of  appetite. 

589.  In  its  simple  form,  scarlet  fever  calls  for  very  little  me- 
dical aid.     An  emetic  of  ipecacuanha  or  antimony;  purging  with 
calomel,  and  afterwards  with  some  one  of  the  neutral  salts;  vene- 
section, in  case  of  fulness  and  pain  in  the  head;  the  mild  diapho- 
retics, aided  by  diluting  drinks;  and  a  regulated  diet,t  are  all  we 
need  prescribe.  But  in  the  anginose  state  of  the  disease,  more  is 
required — the  treatment,  here,  must  be  circumspect  and  vigor- 
ous ;  and  much  reliance  is  to  be  placed  on  the  thorough  evacua- 
tion of  the  alimentary  canal.     Unless,  as  is  sometimes  the  case, 
the  violence  of  the  symptoms  calls  for  the  immediate  use  of  the 
lancet,  let  the  treatment  commence  by  puking  with  ipecacuanha. 
Emetics  are  of  the  highest  importance ;  and  may  sometimes  be 
repeated  during  the  course  of  the  disease,  should  the  symptoms 
be  persevering. 

590.  The  emetic  should  be  followed  by  laxatives.     Calomel 
would  seem  to  be  the  most  suitable,  on  account  of  its  tendency 
to  prevent,  and  remove  congestions  of  the  abdominal  viscera, 
which  are  much  to  be  dreaded,  and  vigilantly  guarded  against, 
in  this  disease.     This  is  a  disease  in  which  congestions  of  the 
great  viscera,    are  very  apt  to  occur;  and  requires    mercurial 
purging  to  unload  the  vessels,  and  restore  the  balance,  which  is 
thus  destroyed  in  the  circulation.     In  the  more  advanced  stages 
of  the  disease,  however,  provided  the  bowels  have  been  already 
fully  evacuated,  some  of  the  milder  purgatives  may  be  employed. 
The  best  mode  of  exhibiting  calomel  is  in  divided  doses — say 
six  or  eight  grains  divided  into  six  parts;  one  part  to  be  given 
every  hour,  until  the  whole  is  taken ;  unless  the  previous  quan- 
tity may  have  answered.     Should  this  quantity  however  fail  to 
move  the  bowels,  it  must  be  followed  by  two  or  three  tea-spoon- 
fuls of  calcined  magnesia,  mixed  in  a  little  sweetened  milk,  and 
drinking  after  it,  some  lemonade. 

,*  When  the  disease  is  very  malignant,  death  sometimes  takes  place  on  the 
third  or  fourth  day;  while  in  its  milder  forms,  it  will  linger  on  to  the  second, 
or  even  third  week.  Generally,  however,  the  patient  is  safe  after  the  ninth 
day,  under  either  form  of  the  disease. 

f  By  a  regulated  diet,  we  mean,  a  strict  antiphlogistic  one;  that  is,  an  entire 
forbearance  from  animal  food;  from  every  kind  of  liquor,  whether  fermented 
or  distilled;  and  from  spices  of  every  species. 

24 


186  SCARLET    FEVER. 

591.  In  case  the  pulse  be  full,  tense,  or  hard,  immediate  re- 
course is  to  be  had  to  venesection.   The  quantity  of  blood  drawn, 
and  the  repetitions  of  the  operation,  are  to  be  directed  of  course, 
by  the  judgment  and  experience  of  the  practitioner.     The  relief 
felt  by  the  patient,  the  appearance  of  the  blood,  and  the  effect 
on  the  pulse,  must  determine,  whether  it  shall  be  repeated — the 
bleeding  must  be  followed  by  purging.     In  the  early  or  inflam- 
matory condition  of  scarlatina,  however,  when  there  is  consi- 
derable arterial  action,  and  vast  augmentation  of  heat  on  the  sur- 
face, cold  ablution,  or  sponging,  gives  great  relief  to  the  symp- 
toms, and  is  a  most  comfortable  process.     We  prefer  sponging 
to  ablutions.     Some  however  are  afraid  of  these  cold  applica- 
tions, because  the  throat  is  sore;  but  this  forms  no  exception; 
for  it  is  not  accompanied  by  cough  or  other  pneumonic  symp- 
toms  like   measles;    and   the   sponging,  or  even  affusion  has 
checked  the  sore  throat  most  evidently.     We  would  however 
make  an  exception  to  the  employment  of  cold  water,  &c.  when 
they  produce  chilliness;  in  this  case  tepid  water  may  be  substi- 
tuted. 

592.  We  are  told  the  warm  bath  is  exceedingly  efficacious, 
when  the  eruption  imperfectly  takes  place,  owing  to  general  lan- 
guor; and  especially  when  attended  by  coldness  of  the  surface — 
or  having  appeared   suddenly  recedes,   inducing  great   gastric 
distress,  and  other  very  unpleasant  symptoms — to  cleanse  the 
foul  ulcers  of  the  throat,  emetics  are  found  most  effectual — the 
emetic  may  be  followed  by  the  use  of  detergent  gargles;  the  best 
of  which  are  composed  of  Peruvian  bark,  with  a  portion  of  the 
tincture  of  myrrh — or,  barley  water,  acidulated  with  the  sul- 
phuric or  muriatic  acid,  with  the  addition  of  honey.  An  infusion 
of  Cayenne  pepper,  alone,  or  mixed  with  barley  water,  or  the 
decoction  of  bark,  is  much,  and  we  have  reason  to  believe  not 
too  much,  praised  as  a  gargle,*  as  far  as  we  can  rely  on  our  own 
observations. 

593.  In  the  malignant  shape  of  this  disease,  the  general  prac- 
tice is  nearly  the  same  as  in  the  preceding  or  anginose  state. 
We  rely  mainly,  on  evacuations  of  the  primae  via? — first,  by  eme- 
tics, and  next  with  the  mercurial  purges. 

594.  Whatever  may  have  been  the  primary  form  of  the  dis- 
ease, in  the  advanced  stages,  when  appearances  of  great  depres- 
sion supervene,  we  have  recourse  to  nearly  similar  measures. 
The  object  is  to  support  the  enfeebled  system,  and  which  is  best 
accomplished  by  the  carbonate  of  ammonia,  camphor,  turpentine, 

*  We  are  in  the  habit  of  using  the  Cayenne  pepper  gargle  in  the  incipient 
stages  of  anginose  affections,  with  the  most  decided  advantage;  and  in  the 
disease  under  consideration,  it  seems  to  us  to  be  the  only  remedy  that  affords 
relief,  if  ulceration  has  not  taken  place. 


SCARLET    FEVER.  187 

bark,  and  wine — aided  by  the  ordinary  external  irritant  applica- 
tions. 

595.  Long  after  the  cessation  of  the  active  symptoms,  there 
are  certain  consequences  show  themselves,  to  which  our  atten- 
tion should  be  immediately  called.     Deafness  is  one  of  these ; 
this  proceeds  from  inflammation  having  invaded  the  Eustachian 
tube,  and  leaving  it  in  a  state  of  obstruction.  It  is  an  unpleasant 
affection,  though  we  have  never  known  any  permanent  mischief 
to  result  from  it;  it  requires  no  treatment*     (Edematous  swell- 
ings of  the  lower  extremities,  are  a  common,  as  well  as  a  more 
serious  inconvenience.     The  best  treatment  is  to  purge  mode- 
rately, and  afterwards  exhibit  the  digitalis.     It  is  here,  that  it 
sometimes  proves  pre-eminently  beneficial.    But  in  the  removal 
of  the  effusion,  it  may  be  aided  by  frictions  and  bandages,  if  the 
swelling  be  large,  and   by  exercise  duly  regulated,  and  perse- 
vering in  a  milk  and  vegetable  diet.     We  have  known  the  in- 
flamed parotids  run  on  to  extensive  suppuration,   and  require 
much  time  for  healing.     When  this  takes  place  during  the  con- 
tinuance of  considerable  fever,  and  the  parts  exposed  by  slough- 
ing look  as  if  they  had  been  carefully  and  beautifully  dissected, 
death  has  constantly  followed,  as  far  as  our  observations  have 
extended. 

596.  Dropsical  affections  frequently  succeed  to  scarlet  fever ; 
this  takes  place  after  the  mild,  as  well  as  after  the  severer  form 
of  this  disease.     We  are  inclined  to  believe,  that  this  affection 
arises  from  the  accompanying  inflammation,   not  having  been 
properly  subdued  by  early  depleting  remedies.    In  consequence 
of  this,  the  inflammation  acquires  a  chronic,  or  a  sub-acute  form, 
which  is  only  relieved  by  purging,  even  by  blood-letting,  and 
diuretics  of  the  saline  kind ;  as  nitre,  or  nitre  and  squills.     For 
children  under  seven  years,  and  above  three,  we  would  give 
eight  grains  of  nitre  and  one-fourth  of  a  grain  of  squills  three  or 
four  times  a  day.  For  those  above  seven  to  fifteen,  twelve  grains 
of  nitre,  and  half  a  grain  of  squills  may  be  given;  from  fifteen  to 
adult  age,  from  fifteen  to  twenty  grains  of  nitre,  and  a  grain  of 
squills  may  be  administered. 

597.  Much  has  been  said  of  the  preventive  powers  of  bella- 
donna in  scarlet  fever,  in  various  parts  of  Europe,  especially  in 
Germany;  and  as  every  thing  that  can  possibly  diminish  the 
frequency  or  abate  the  danger  of  this  oftentimes  formidable  dis- 
ease is  eagerly  sought  after,  we  have  thought  it  proper  to  intro- 
duce in  this  place  a  summary  of  what  has  been  urged  in  favour 
of  the  prophylactic  powers  of  this  active  drug ;  and  at  the  same 
time  to  contrast  these  newly-raised  expectations  with  what  ap- 

*  Dr.  Gregory  states,  that  "not  unfrequently  permanent  deafness  is  left  by 
it."     Vol.  I.  p.  240.     Of  this  however  we  have  never  seen  an  example. 


188  SCARLET    FEVER. 

pears  to  be  a  fair  and  candid,  and  at  the  same  time  a  sufficiently 
extensive  experience  upon  this  point — nevertheless  declaring  our 
entire  want  of  confidence  in  this  medicine,  or  perhaps  any  other, 
to  prevent  the  accession  of  scarlet  fever ;  especially  when  epi- 
demic ;  a  time  of  all  others  at  which  it  would  be  useful.  In  mat- 
ters of  so  much  moment  as  the  one  under  consideration,  negative 
proofs  of  the  efficacy  of  any  means  are  not  always  to  be  relied 
upon;  we  should  always  endeavour,  in  making  propositions  in 
which  the  lives  and  happiness  of  our  fellow  creatures  are  involv- 
ed, to  arrive  at  absolute  certainty,  as  far  as  this  is  practicable,  be- 
fore they  are  confidently  promulgated  to  the  public  to  be  acted 
upon.  Had  this  plan  been  adopted  as-regards  the  preventive 
powers  of  the  belladonna,  we  believe  we  should  have  heard  of 
no  positive  testimony  in  its  favour. 

"  Belladonna  a  Preventive  of  Scarlet  Fever." 

598.  "It  has  been  long  known  that  Dr.  Hahnemann,of  Leipsic, 
has  asserted  the  above  fact — but,  since  the  year  1818,  several 
practitioners  in  the  north  of  Europe  have  repeated  these  experi- 
ments, and  they  find  them  founded  on  truth.   The  first  of  these, 
Dr.  Brendt,  of  Custrin,  affirms  that  all  who  employed  this  re- 
medy escaped  the  infection — and  his  account  is  corroborated  by 
Dr.  Mushbeck,  of  Demmin,  in  Western  Pomerania,  who  says 
he  has  used  it  for  seven  years,  and  with  equal  success — and  he 
administered  it  to  all  those  who  dwelt  in  the  houses  where  scarlet 
fever  prevailed,  continuing  its  use  until  desquamation  of  the 
cuticle  had  taken  place  in  those  attacked.     Dr.  Dusterbourg,  of 
Warbourg,  has  also  published  an  account  of  a  series  of  experi- 
ments, confirming  those  statements — and  several  subsequent  me- 
moirs have  appeared,  all  equally  corroborative  of  this  virtue  in 
the  belladonna.    The  formula  generally  recommended,  is  a  solu- 
tion of  two  grains  of  the  extract  in  an  ounce  of  some  distilled 
water — and  to  children  from  one  to  ten  years  of  age,  from  one 
to  five  drops  of  this  solution  is  given  four  times  in  the  day — 
from  ten  years  of  age  and  upwards,  from  six  to  ten  drops  is 
given,  also  four  times  in  the  twenty-four  hours."* 

"  Belladonna  in  Scarlatina." 

599.  "  In  the  last  volume  of  the  Philadelphia  Journal  of  the 
Medical  and  Physical  Sciences,  will  be  found  some  observations 
which  are  highly  favourable  to  the  efficacy  of  the  belladonna  as 
a  preservative  against  scarlatina.    Dr.  Lehman  has  published,  in 

*  Philada.  Med.  &  Phys.  Journ.  from  the  Revue  Medicale,  Juin. 


SMALL-POX.  189 

the  twenty-second  volume  of  Rust's  Magazine,  a  memoir,  in 
which  he  observes  that  an  epidemic  scarlatina  prevailed  at  Tor- 
gan,  in  1825,  of  so  violent  a  character,  that  one  in  eight  of  those 
afflicted  with  it  died,  and  that  thirty  patients,  all  of  tender  age, 
fell  victims  to  it.  The  belladonna  was  administered  with  confi- 
dence, in  many  families  in  which  the  disease  appeared,  and  there 
could  be  no  doubt  of  the  good  quality  of  the  extract  employed ; 
nevertheless  it  did  not  act  either  as  a  preservative,  nor  did  it 
mitigate  the  violence  of  the  disease.  Dr.  L.  did  not  perceive 
any  difference  either  in  the  violence  of  the  disease,  or  its  results, 
when  it  attacked  those  who  had  taken  the  belladonna,  even  for 
a  long  time  and  in  large  doses,  and  those  who  had  never  taken 
the  medicine." 


CHAPTER  IV. 

OF  SMALL-POX. 

600.  It  were  seriously  and  ardently  to  be  wished,  that  this  fatal 
and  loathsome  disease,  no  longer  required  noticein  workson  prac- 
tical medicine — but  alas!  we  fear  this  important  change  is  not 
to  be  effected  in  our  day.     It  was  fondly  hoped;  nay,  confident- 
ly expected,  that  the  discovery  of  Jenner,  would  have  rid  man- 
kind from  this  cruel  scourge,  at  no  very  distant  period;  but  un- 
fortunately, it  has  not  so  far  answered  our  fondly  indulged 
hopes,  of  extermination,  though   it   has   much    mitigated   the 
violence  and  danger  of  small-pox,  as  well  as  greatly  abridged  its 
ravages.     Its  frequent  appearance  in  towns,  villages,  and  coun- 
tries, without  our  being  able  to  say  from  whence  it  came,  or  by 
whom,  pr  what  introduced,  keeps  the  mind  of  such,  as  have  not 
passed  its  ordeal,  constantly  in  fear  of  its  visitation;  and  in  per- 
petual dread  of  its  consequences.     This  being  the  case,  we  have 
thought  it  proper  to  notice  it  in  the  present  edition  of  this  work, 
though  we  have  nothing  new  to  offer  on  either  its  history,  or  its 
treatment. 

History. 

601.  It  seems  to  be  conceded  upon  all  hands,  that  the  small- 
pox, was  fir&t  known  in  the  east;  and  this  for  several  centuries, 
before  it  travelled  even  so  far  west,  as  Europe.   Moore  in  his  his- 
tory of  this  disease,  renders  it  more  than  probable,  that  it  was 


190  SMALL-POX. 

known  in  both  China  and  Hindostan  from  a  very  remote  period  of 
time;  and  that  it  did  not  reach  Europe,  until  about  the  sixth 
century.  During  the  latter  part  of  the  sixth,  and  of  all,  the 
seventh  century,  it  spread  over  parts  of  both  Asia  and  Africa; 
and  especially,  that  part  of  the  latter,  that  borders  on  the  Medi- 
terranean Sea.  In  the  eighth  century  Europe  became  its  seat; 
by  the  invasion  of  Italy,  Spain,  Sicily,  and  France,  by  the 
Saracens.  It  then  travelled  north;  and  Saxony,  Switzerland  and 
England,  were  visited  by  this  dreadful  plague,  in  the  latter  part 
of  the  ninth,  and  beginning  of  the  tenth,  centuries.  From  these 
places,  but  especially  from  Spain,  it  was  made  to  visit  South 
America  in  the  sixteenth  century,  very  soon  after  the  death  of 
Columbus.  And  from  this  period  to  the  present  moment,  it  ap- 
pears to  be  occasionally  in  possession  of  almost  every  portion  of 
the  habitable  world.  The  first  account  of  this  malady  was  given 
to  Europe,  at  the  end  of  the  ninth  century,  by  Rhazes,  an  Arabian 
physician  of  great  talent,  but  who  quotes  a  preceding  account, 
by  Aaron,  of  Alexandria. 

602.  Dr.  Good  remarks  of  the  history  of  the  small-pox  by 
both  these  authorities,  as  a  circumstance  of  remarkable  singu- 
larity, that  neither  of  these  authors  mention  the  contagious  na- 
ture of  this  disease.     And  that  it  is  equally  singular  that  Aaron, 
should  assert,  that  the  same  person  is  liable  to  the  disease  a  se- 
cond or  even  a  third  time.     The  Dr.  asks,  "  has  the  disease  un- 
dergone any  change  since  that  period  so  as  to  render  those  who 
have  not  had  it,  more  susceptible  of  its  influence,  and  those  who 
have  had  it,  less?     In  the  descriptive  part  of  the  disease  little  is 
to  be  added  to  Rhazes'  statement;  and  what  is  more  singular,  he 
recommends  the  cool  treatment."  p.  412. 

Symptoms. 

603.  Physicians  have  divided  this  disease  into  two  kinds,  or 
varieties;  for  they  cannot  be  looked  upon,  as  species.  Dr.  Good 
indeed,  after  the  fashion  of  some  others,  makes  three ;  though  we 
cannot  see  any  thing  in  his  third  division  beyond  a  variation, 
most  probably  arising  from  the  state  of  the  system  at  the  time 
of  invasion.  Indeed,  the  same  may  be  said  of  the  more  generally 
acknowledged  division  into  distinct,  and  confluent;  for  we  are 
perfectly  convinced  it  does  not  depend  upon   the  nature  of  the 
virus  or  remote  cause,  as  we  have  seen  the  same  matter  produce 
the  two  different  varieties — nay,  we  have  a  number  of  times  seen 
the  distinct  small-pox  produced  by  the  matter  of  the  confluent. 
Yet  there  are  considerable  differences,  in  the  phenomena  of  the 
two  states  of  the  disease.  In  the  distinct  small-pox,  the  pustules 
are  large,  and  distinct ;  they  are  well  filled,  and  round ;  the  fluid 


SMALL-POX.  191 

when  well  concocted,  or  at  its  height,  when  discharged  by  punc- 
ture, has  nearly  the  appearance  of  ordinary  pus.  While  in  the 
confluent,  the  pustules  run  into  each  other;  are  ill  filled  and 
flattened  at  top;  are  irregular  in  their  form,  and  the  spaces  be- 
tween the  pustules,  are,  like  the  pustules  themselves,  pale.  Yet 
each  of  these  have  several  corresponding  symptoms ;  as  fever, 
thirst,  head-ache,  white  tongue,  chilliness,  and  hot  skin. 

Distinct. 

604.  The  eruption  is  preceded  by  chill,  vomiting,  and  some 
soreness  of  throat;  and  almost  uniformly  first  appears  upon  the 
face,  neck,  and  breast.   It  assumes  the  form  of  small  red  papula;, 
and  much  resembles  flea-bites.     About  the  fourth  day,  the  erup- 
tion becomes  distinctly  vesicular,  with  slight  depressions  in  the 
centre  of  each  pustule,  which  now  contains  a  fluid,  or  lymph; 
at  first  this  is  transparent;  but  about  the  sixth  day,  it  becomes 
well  filled  with  a  thick  pus — each  pustule  has  an  inflamed,  cir- 
cumscribed margin,  of  greater  or  less  intensity,  which  continues, 
until  the*  fluid  within  it,  becomes  thick  and  disposed  to  dry. 
This  redness  or  inflammation,  is  always  more  intense  when  the 
pustules  are  numerous,  and  the  parts  became  swollen.     Indeed, 
there  is  a  strong  disposition  to  effusion  in  the  variolous  inflam- 
mation— hence,  the  eyelids,  especially,  and  the  whole  face,  be- 
comes swollen;  and  this  in  proportion  to  the  degree  of  eruption. 
So  much  so  is  this  the  case,  where  the  pustules  are  numerous, 
that  the  eyelids  become  closed,  and  temporary  blindness  ensues. 
The  fever,  which  never  fails  to  attend  this  disease,  is  of  a  high 
inflammatory  character — hence,  the  intensity  of  the  pustular  in- 
flammation, and  its  extreme  sensibility.     About  the  eighth  or 
ninth  day,  the  suppurative  process  in  the  pustules  is  complete. 
The  fever  now  abates;  and  the  pustules  begin  to  diminish  in  size, 
and  to  lose  their  redness.  On  the  eleventh,  these  little  abscesses 
begin  to  dry,  and   look  brown;  and  in  a  few  days  more,  they 
desquamate;  especially  those,  on  the  superior  part  of  the  body — 
those  on  the  lower  portion,  require  a  little  longer  time. 

605.  As  a  general  rule  it  may  be  remarked,  that  the  severity 
of  symptoms,  bear  a  very  regular  proportion  to  the  extent  of  the 
eruption — hence,  when  this  disease  is  ushered  in  by  a  strong 
pyrexia,  intense  pain  in  the  head  and  back,  and  great  disturbance 
of  the  stomach,  the  eruption  will  be  of  proportionate  extent,  and 
the  danger  commensurate  with  both.     Thus  we  find  when  the 
pustules  are  few,  distinct,  and  wide  apart,  the  accompanying 
symptoms  are  comparatively  mild,  and  we  might  say,  propor- 
tionably  free  from  danger.     While  on  the  other  hand,  when  the 
pimples  are  very  numerous,  and  very  contiguous  to  each  other, 


192  SMALL-POX. 

the  symptoms  bear  a  more  aggravated  form,  and  risk  is  aug- 
mented. 

606.  Four  distinct  stages  are  pretty  strongly  marked,  when 
this  disease  assumes  an  intense  form — first,  the  precursive;  se- 
cond, the  eruptive;  third,  the  maturating;  fourth,  the  desqua- 
mating, or  scabbing.     Each  of  these  stages,  is  marked  in  their 
commencement  by  an  increase,  of  the  febrile  symptoms. 

607.  It  is  not  unfrequent,  that  the  attack  of  small-pox,  whe- 
ther it  be  the  natural,  or  the  induced,  is  ushered  in  by  convul- 
sions— this  is  especially  the  case,  with  children.     And  what  is 
remarkable,  this  alarming  symptom  is  frequently  the  presage  of 
a  mild  disease ;  especially,  if  it  be  the  inoculated  small-pox,  not- 
withstanding Dr.  Good  says,  it  "was  the  custom  to  make  much 
lighter  of,  than  the  occasion  justifies." 

Pathology. 

608.  The  pathology  of  small-pox  has  been  but  very  partially 
treated  of,  even  by  professed  systematic  writers — this  we  sup- 
pose has  been  chiefly  owing,  to  the  occupation  of  the  skin  by  the 
pustules,  being  thought  sufficient,  to  account  for  the  other  phe- 
nomena of  the  disease.   Dr.  Mackintosh  has  however,  given  us 
the  following  account  of  his  own  pathological  researches  in  small- 
pox.    He  says,    "  I  have  seen  marks  of  inflammation  of  the 
membranes,  evinced  by  a  considerable  arborescent  vascularity 
on  the  surface  of  the  brain  ;  the  vessels  of  the  pia  mater  being 
greatly  loaded  with   blood;  together  with  effusion  under  the 
arachnoid,  and  into  the  ventricles."     He  however  adds,  "  but  it 
becomes  me  to  speak  with  diffidence  with  respect  to  this  part  of 
the  subject,  as  Dr.  George  Gregory  says  that  he  has  '  never 
been  able  to  trace  any  morbid  appearances  in  the  head,'  which 
is  rather  at  variance  with  the  results  of  my  limited  experience, 
and  with  a  statement  he  subsequently  makes.     In  directing  the 
mode  of  treatment,  he  says,  *  it  is  to  be  remembered  also,  that 
in  small-pox,  fully  as  much  as  in  any  other  form  of  fever,  there 
is  a  tendency  to  congestions  and  inflammation  in  the  head  and 
thorax. ' 

609.  "Although  Ihavebeen  prevented  by  the  impatience  of  sur- 
vivingfriends,  from  opening  the  head  as  often  as  I  could  have  wish- 
ed, yet  many  opportunities  have  been  afforded  to  me  of  examining 
the  contents  of  the  thorax  and  abdomen.   I  have  seen  pustules  in 
the  pharynx,  larynx,  trachea,  and  oesophagus,  in  those  who  died 
by  the  twelfth  or  thirteenth  day ;  on  some  occasions  closing  up  the 
larynx.     The  mucous  membrane  of  the  bronchi  very  vascular; 
and  the  air  tubes  completely  gorged  with  matter,  most  frequently 
of  a  reddish  colour;  but  in  no  instance  have  I  been  able  to  dis- 


SMALL-POX.  193 

cover  pustules  below  the  bifurcation.  The  substance  of  the  lungs 
congested  with  blood ;  and  in  the  first  and  second  stages  of  in- 
flammation, and  in  one  instance,  there  was  pleuritic  effusion.  In 
examining  the  body  of  a  deformed  girl  who  died  under  an  at- 
tack of  confluent  small-pox,  the  peritoneum  and  pleura  were  both 
studded  over  with  small  circular  spots,  which  looked  like  a  faded 
eruption;  but  perhaps  they  might  have  been  produced  in  the 
manner  which  we  sometimes  see  in  cases  of  purpura.  I  have 
seen  nothing  in  the  stomach  to  account  for  the  severe  burning 
pain  complained  of  in  the  epigastric  region  ;  the  mucous  mem- 
brane has  certainly  shown  vascularity,  and  has  been  covered 
with  a  viscid  exudation,  and  the  follicles  very  much  increased  in 
size,  which  appearance  very  often  extends  throughout  the  whole 
intestinal  tube ;  and  in  three  instances,  I  have  seen  pustules,  or 
vesicles  having  a  pustular  appearance,  with  a  depression  in  the 
centre,  in  the  jejunum,  ileum,  and  also  in  the  large  intestines;" 
"  and  some  of  them  were  surrounded  by  an  inflammatory  areo- 
la."  Practice  of  Physic,  Vol.  I.  p.  148. 

Treatment. 

610.  In  small-pox,  be  the  variety  which  it  may,  the  primary 
and  most  important  indication,  is  the  reduction  of  fever.     This 
must  be  attempted,  by  every  means  that  has  been  found  useful 
in  other  phlogistic  diseases — by  blood-letting,  where  the  tension 
and  fulness  of  the  pulse  would  justify  this  evacuation  in  any 
other  inflammatory  disease ;  by  purging,  especially  by  calomel, 
and  the  neutral  salts;  by  cold  drinks  liberally  administered;  and 
by  cool  air  being  freely  admitted ;  by  frequent  changes  of  bed 
and  body,  clothes;  by  a  strict  antiphlogistic  regimen;  and  by 
keeping  the  patient  upon  a  mattrass  or  sacking-bottom  when 
practicable,  instead  of  being  placed  upon  a  feather  bed ;  by  spare 
covering  of  bed-clothes,  &c. 

Confluent. 

611.  We  have  already  given  the  pathognomonic  characters  of 
this  variety  of  small-pox.     The  efflorescence  is  diffused  and  ge- 
neral, without  those  points  which  in  the  distinct,  mark  the  loca- 
tion of  a  pustule.    About  the  third  day  an  extended  elevation  of 
the  skin,  with  considerable  roughness,  betray  an  attempt  at  the 
formation  of  pustules,  but  are  prevented  from  being  distinct,  by 
their  general  coalescence,  and  forming  themselves  into  larger  or 
smaller  patches. 

612.  These  blotches,  or  assemblages  of  imperfect  pustules,  are 
ill  filled  and  much  less  pronounced,  than  the  pustules  of  the  dis- 

25 


194  SMALL-POX. 

tinct,  small-pox;  and  unlike  the  latter,  are  filled  with  a  yellowish 
serum ;  and  oftentimes,  in  many  places  on  the  same  individual, 
with  a  kind  of  bloody  ichor,  which  is  never  converted  into  a 
healthy  pus.  The  fever  is  for  the  most  part  violent;  and  its  type 
is  synochus,  or  tj'phus;  but  which  does  not  abate  with  the  pro- 
gress of  the  eruption  ;  on  the  contrary,  it  very  frequently  aug- 
ments, as  this  advances.  The  eyes  are  inflamed,  and  their  lids 
much  swollen;  the  head  is  confused  ;  and  not  unfrequently  deli- 
rium or  coma  succeed.  A  salivation,  more  or  less  profuse,  keeps 
time  with  the  eruption;  at  first,  this  is  thin,  and  it  readily  flows 
from  the  mouth;  but  it  soon  becomes  very  ropy,  and  viscid,  and 
is  discharged  with  much  difficulty.  In  children,  a  diarrhoea 
sometimes  supervenes.  About  the  eighth  day  the  covering  of 
these  irregular  pustules  becomes  brown,  or  nearly  black,  instead 
Of  yellow  as  in  the  distinct  variety.  The  patient  usually  dies  on, 
or  about  the  eleventh  day,  though  he  may  live  to  the  sixteenth. 

Prognosis. 

613.  The  distinct  small-pox  is  rarely,  or  never  fatal — not  so 
the  confluent.  Indeed  we  should  ever  be  cautious  in  pronouncing 
favourably  of  this  variety.     When  it  is  about  however  to  termi- 
nate favourably,  we  find  the  swelling  of  the  face  to  diminish, 
while  the  extremities  become  swoln.    The  salivation  diminishes 
in  quantity,  and  loses  much  of  its  viscidity.     The  pustules,  or 
rather    blotches,   commence  turning,  or  become  brown,    upon 
the  face;  and  this  progresses  regularly,  and  slowly,  to  the  extre- 
mities.    But  on  the  other  hand,  if  the  secondary  fever,  or  that 
fever  which  is  sure  to  take  place  at  this  time,  be  violent;  if  the 
pustules  suddenly  shrink,  become  white,  and  flatten  themselves; 
if  the  features  sink ;  if  the  saliva  become  extremely  tenacious  and 
scanty;  if  coma,  or  delirium  increase;  if  little  red  spots  resem- 
bling flea-bites  be  sprinkled  over  the  body,  followed  by  bleed- 
ings from  various  parts  of  the  surface ;  if  the  pulse  become  ex- 
tremely quick  and  fluttering,  with  a  strong  action  of  the  heart, 
the  patient  will  rarely  continue  beyond  the  eleventh  day. 

Treatment. 

614.  More  caution  is  required  in  the  management  of  this  va- 
riety of  small-pox,  than  in  the  distinct  variety ;  though  we  must 
be  guided  in  the  treatment,  by  the  same  general  plan.   Bleeding 
should  be  used  with  great  caution  after  the  third  day;  and  no- 
thing will  justify  the  abstraction  of  blood  previously,  but  a  strong, 
hard  pulse.     We  are  however,  every  way  certain  in  our  own 
minds,  that  when  this  state  of  pulse  is  present ;  and  especially, 


MODIFIED    SMALL-POX.  195 

where  there  is  much  vomiting,  and  much  tenderness  of  the  epi- 
gastrium, that  the  abstraction  of  blood  has  been  found  highly 
useful,  though  we  were  persuaded  that  the  patient  would  have 
the  confluent  small-pox.  Purging,  we  think,  can  never  be  dis- 
pensed with,  in  the  beginning  of  the  disease;  and  the  mercurial 
purges  given  at  pretty  long  intervals,  appear  to  answer  best.  The 
same  attention  must  be  paid  to  the  admission,  and  the  frequent 
renewal  of  fresh  air.  The  drinks  should  also  be  cool,  and  mu- 
cilaginous; all  animal  substances  must  be  strictly  forbidden;  and 
if  the  body  require  support,  the  farinaceous  and  mucilaginous 
substances  should  be  selected — such  as  rice,  tapioca,  sago,  arrow- 
root, or  gum  Arabic.  In  this  state  of  things  camphor  has  been 
warmly  recommended,  aided  by  wine-whey,  or  milk-punch — 
but  we  are  of  opinion,  that  either  of  these  substances,  have  al- 
ways augmented  the  secondary  fever.  Opening  of  the  pustules 
is  useful,  as  it  seems  to  abate  the  severity  of  this  adventitious 
excitement  of  the  system,  by  diminishing  a  very  extensive  source 
of  irritation  and  pain.  For  each  pustule  is  an  abscess  in  minia- 
ture; and  the  quantum  of  relief,  is,  like  any  other  collection  of 
pus,  in  proportion  to  the  size  of  the  abscess.  It  has  however 
been  thought  by  some,  (indeed  it  is  a  popular  belief,)  that  it  in- 
creases the  pitting ;  but  our  experience,  leads  us  to  reject  this 
opinion. 

SECT.  I. — MODIFIED  SMALL-POX,  OR  VARIOLA  VACCINA,  OR 

COW-POX. 

615.  We  shall  not  notice  one  of  the  means  by  which  this  terrific 
disease  is  rendered  milder,  and  very  much  less  fatal,  than  when 
it  is  accidently  introduced  into  the  system,  namely,  inoculation; 
as  we  trust,  the  other,  (vaccination,)  has  procured  for  itself  so 
much  confidence,  that  it  will  always  obtain  a  preference.     It 
would  be  a  flagrant  waste  of  time,  to  recapitulate  the  arguments 
in  favour  of  vaccination ;  or  to  enter  into  the  unprofitable  en- 
deavour to  account  for  the  melioration  of  this  disease  by  this 
process — it  is  now  sufficiently  conceded,  that  it  is  vastly  prefer- 
able in  every  point  of  view — it  is  a  very  much  more  mild  dis- 
ease, if  we  only  regard  the  local  irritation  or  inflammation;  and 
we  are  steadfastly  of  opinion,  it  is  equal,  in  its  protective  powers. 
We  shall  therefore  earnestly  recommend  its  adoption,  to  the  en- 
tire exclusion  of"  Inoculation." 

616.  In  describing  this  operation,  and  the  progress  of  the  ar- 
tificial disease,  we  shall  merely  lay  down  a  few  general  rules 
upon  the  subject ;  leaving  any  deviation  from  them,  to  the  good 
sense,  and  experience,  of  the  operator. 

617.  First.   It  seems  to  be  agreed  that  the  subject  of  this  ope- 


196  MODIFIED    SMALL-POX. 

ration  had  better  acquire  at  least  three  months  of  age,  before  vac- 
cination is  attempted. 

618.  Second.  The  child  should  be  in  good  health  at,  the  time 
selected — that  is,  it  should  be  free  from  all  vascular  irritation — 
as  severe  teething,  fever,  or  catarrhal  affections;  though  we  never 
hesitate  to  insert  vaccine  virus  in  children,  who  are  labouring 
under  cuticular  eruptions. 

619.  Third.  The  left  arm  is  generally  chosen — the  spot  se- 
lected for  the  insertion  of  the  virus  is  on   its  anterior,  central 
portion;  or  at  the  termination  or  insertion,  of  the  deltoid  muscle. 

620.  Fourth.   The  scab,  is  now  almost  universally  chosen*— 
a  very  small  portion  of  which  is  to  be  finely  ground  between  two  • 
pieces  of  glass,  and  then  moistened  sufficiently,  (but  not  too 
much  diluted,)  by  a  very  small  drop  of  water.     When  thus  pre- 
pared, it  is  to  be  collected  upon  the  point  of  a  lancet,  and  from  this 
delivered  upon  the  spot  selected  on  the  arm,  by  wiping  the 
charged  portion  of  the  lancet  up  it.    Then,  with  the  point  of  the 
lancet,   let  the   skin    immediately  under  the   virus,    be  very 
slightly  irritated  by  frequently  touching  it  in  several  places,  with 
the  point  of  the  lancet,  until  a  very  feint  appearance  of  blood  is 
produced — now  desist,  and  allow  the  part  to  be  exposed  until  the 
matter  dry  upon  it.     Care  is  now  to  be  taken,  that  the  part 
be   not  disturbed  by  unnecessary  washing,  or  by  rudely  hand- 
ling it.     About  the  fifth  day,  if  the  operation  have  been  success- 
ful, a  small  point  of  inflammation  will  be  perceived,  which  will 
gradually  increase,  from  day  to  day,  until  a  complete  pustule  is 
formed,  surrounded  by  a  beautiful  blush,  or  areola — this  usually 
takes  place  from  the  ninth,  to  the  tenth  day.     Caution  is  re- 
quired, that  the  pustule  be  not  injured  by  some  mechanical  vio- 
lence; for  it  is  of  consequence  to  preserve  its  integrity  through- 
out the  whole  course  of  the  disease. 

621.  Fifth.  After  a  few  days  continuance,  the  areola  loses  the 
intensity  of  its  colour — the  fluid  in  the  pustule  becomes  thicker; 
and  acquires  a  dark  mahogany  hue — the  pustule  is  depressed  in 
its  centre — the  epidermis  cracks  around   it;  and  on  about  the 
sixteenth,  or  seventeenth  day,  drops  off.     Much  care  should  be 
taken,  that  it  be  not  rudely  detached  by  force  or  violence;  and 
thus  become  lost  to  the  purposes  of  the  operator.     To  prevent 
this  happening  to  the  scabs  we  select  for  use,  we  place  a  piece 
of  court  plaster  over  the  dried  pustule,  and  suffer  it  to  remain  on, 
until  it,  with   the  scab,  spontaneously  detach  themselves  from 
the  arm — by  this  means  we  are  sure  to  preserve  the  scab.     We 
are  not  in  the  habit  of  purging  after  this  disease;  or  of  subjecting 
the  child  to  any  medical  discipline,  during  its  progress. 


URTICARIA,  OR  NETTLE  RASH.  197 


CHAPTER  V. 

URTICARIA,  OR  NETTLE  RASH. 

622.  THIS  very  troublesome,  and  sometimes  obstinate  com- 
plaint, is  wont  to  attack  children  who  are  teething,  or  who  in- 
dulge much  in  ascescent  food,  or  fruits ;  especially  in  the  summer 
season. 

623.  Dr.  Good  defines  the  idiopathic  species  to  be — "  rash  in 
florid,  itching,  nettle  sting  weals,  appearing  about  the  second 
day ;  irregularly  fading  and  reviving,  or  wandering  from  part  to 
part:  fever  a  mild  remittent."  Vol.  II.  p.  384.     This  definition 
may  be  correct  in  what  Dr.  Good  calls  the  idiopathic  form  of 
urticaria ;  but  there  are  some  remarkable  deviations  from  it.  We 
have  seen  many  instances  of  this  complaint  come  on  very  sud- 
denly, when  certain  articles  had  been  taken  into  the  stomach, 
and  which  was  only  relieved,  by  these  substances  being  again 
discharged  from  it.     We  knew  a  gentleman  in  whom  this  com- 
plaint has  been  several  times  produced  by  eating  of  very  young 
boiled  chickens;  when  roasted  or  broiled  they  would  not  affect 
him;  by  boiled  young  cabbage  in  the  spring  of  the  year;  by  a 
draft  of  cold  lemonade  when  his  body  was  over-heated.     After 
either  of  these  substances  had  been  received  into  the  stomach  a 
few  minutes,  he  would  become  violently  sick;  would  vomit,  and 
in  a  moment  be  covered  with  weals,  which  would  remain  until 
he  would  effectually  cleanse  his  stomach  from  the  offending 
matter. 

624.  Dr.  Hewson  mentions  several  cases  of  eruptions  which 
arose  from  taking  of  balsam  copaiba ;  some  resembled  the  weals 
of  urticaria,  others  erythema,  or  roseola.     We  have  also  seen 
these  effects  from  the  balsam.     Strawberries  sometimes  gives 
rise  to  urticaria;  we  knew  a  lady  who  never  failed  to  have  it  after 
eating  this  fruit. 

625.  This  is  a  very  troublesome  complaint  in  consequence  of 
the  excessive  itching  which  always  attends  it.   It  is  almost  always 
accompanied  by  sickness  of  stomach,  head-ache,  giddiness,  and 
great  disposition  to  become  chilly,  upon  the  slightest  exposure 
of  any  portion  of  the  body.     The  fever  which  attends,  may  be 
of  greater  or  less  violence;  but  it  almost  always  observes  an 
evening  exacerbation,  at  which  time,  all  the  symptoms  are  in- 
creased, and  especially  the  itching.     The  weals  which  appear 
upon  the  skin,  are  sometimes  very  extensively  spread  over  it ; 


198  URTICARIA,    OR    NETTLE    RASH. 

and  at  other,  confined  to  certain  portions  of  it,  especially  upon 
the  inner  surface  of  the  forearms,  and  inside  of  the  thighs. 

626.  From  the  surface  of  the  weals  there  issues  an  acrid  se- 
rum,  or   lymph,   which  serves   to    perpetuate,   or  renew   the 
itching ;  and  such  is  the  disposition  of  the  skin,  while  labour- 
ing under  this  affection,  that  you  may  at  pleasure,  if  the  fever 
be  considerable,  produce  a  continued  eruption,  by  drawing  the 
nail  forcibly  over  the  skin,  at  almost  any  portion  of  it.     This 
eruption  sometimes  disappears  as  suddenly  as  it  had  showed  it- 
self; and  when  this  is  the  case,  serious  consequences  have  some- 
times resulted,  though  the  disease  is  very  rarely  fatal.     We  but 
once  have  witnessed  danger  from  the  retrocession  of  this  erup- 
tion.    In  this  case  the  patient  had  previously  several  attacks  of 
an  intermittent,  from  which  she  had  been  relieved  each  time  by 
the  sulphate  of  quinine.  Her  health  appeared  to  be  rapidly  mend- 
ing for  some  time,  and  she  had  nearly  acquired  her  wonted 
strength;  when  very  early  one  morning  she  was  attacked  with 
urticaria  to  which  she  had  been  occasionally  liable. 

627.  Soon  after  it  made  its  appearance  she  became  extremely 
sick,  and  vomited  very  freely;  she  complained  of  a  severe  pain 
in  the  head,  which  was  quickly  followed  by  delirium.     At  this 
time  we  saw  her;  besides  the  symptoms  just  named,  we  found 
her  extremely  restless,  throwing  herself  into  a  variety  of  posi- 
tions, as  if  unable  to  keep  quiet  for  a  moment. 

628.  The  face  was  cadaverous,  and  evinced  much  uneasiness. 
Her  intellect  was  not  sufficiently  collected  to  give  any  rational 
answer  to  our  questions. 

629.  The  extremities  were  cold,  the  pulse  nearly  extinct,  and 
the  breathing  very  laborious;  in  a  word,  her  situation  was  truly 
alarming.     Hot  applications  were  made  to  the  feet  and  legs;  a 
very  large  warm  sinapism  was  applied  to  the  region  of  the  sto- 
mach ;  and  ten  grains  of  the  carbonate  of  ammonia  were  ordered 
every  hour,  together  with  a  spoonful  of  hot  brandy  toddy  every 
few  minutes. 

630.  The  parts  of  the  body  from  which  the  eruption  had  dis- 
appeared exhibited  a  motled,  livid  hue;  other  portions  of  the 
skin  were  "  goose-fleshed"  to  a  great  degree.   The  bowels  were 
spontaneously  opened,  at  the  time  the  puking  took  place;  and 
she  passed  a  large  quantity  of  urine.     We  saw  our  patient  after 
an  interval  of  two  hours,  and  found  her  in  rather  a  more  favour- 
able situation,  but  very  far  from  being  relieved. 

631.  The  legs  and  feet  were  a  little  warmer,  but  the  mustard 
had  scarcely  acted  upon  the  skin.  The  volatile  alkali,  and  brandy 
toddy  sat  well  upon  her  stomach;  the  delirium  was  somewhat 
abated;  and  the  whole  skin  looked  more  natural.     The  reme- 
dies were  ordered  to  be  continued. 


URTICARIA,    OR    NETTLE    RASH.  199 

632.  At  the  end  of  two  more  hours,  we  again  visited  our  pa- 
tient, and  found  her  much  amended — that  is,  the  warmth  of  the 
body  greater,  and  more  natural ;  the  delirium  and  jactitation  less; 
the  pulse  more  open ;  the  countenance  more  natural,  and  less  dis- 
tressed ;  but  no  return  of  the  eruption.    Remedies  were  ordered 
to  be  continued. 

633.  In  the  evening,  upon  our  return,  we  found  a  pretty  plen- 
tiful crop  of  the  eruptive  weals,  attended  by  much  itching.   The 
warmth  of  the  skin  rather  above  the  natural  standard  ;  the  deli- 
rium was  gone;  the  inquietude  over.     The  volatile  alkali  and 
brandy  were  suspended ;  a  liberal  dose  of  magnesia  ordered,  and 
a  little  chicken  water,  from  time  to  time,  was  allowed.     On  our 
visit  on  the  following  morning  we  found  our  patient  feeble,  but 
relieved  from  the  eruption,  and  free  from  fever.     She  was  soon 
after  restored  to  health. 

634.  It  would  be  difficult  to  say  what  may  be  the  cause  of 
idiopathic  urticaria;  be  this  what  it  may,  the  force  of  the  disease 
is  chiefly  spent  upon  the  cutaneous  system;  but  with  which  the 
stomach  is  sure  to  sympathize:  or  the  stomach  may  be  the  seat 
of  the  affection,  and  the  skin  sympathize  with  it.     It  sometimes 
becomes  chronic,  and  we  have  known  several  young  people 
liable  several   times  in  the  year  to  returns  of  it,  without  any 
evident  exciting  cause. 

635.  This  disease,  however,  is  much  more  frequently  a  sym- 
pathetic affection,  arising  sometimes  from  difficult  dentition,  and 
at  others  from  some  offensive  substance  taken  into  the  stomach ; 
this  is  especially  the  case  with  children  until  the  age  of  puberty. 
Acids  of  every  kind  seem  capable  of  producing  it — hence  the 
frequency  of  its  appearance  after  crude  fruit,  cucumbers,  young 
cabbage,  lemonade,  when  the  body  is  heated,  &c.     The  plan  of 
treating  this  complaint  is  in  conformity  to  the  condition  of  the 
stomach;  for  whether  this  disease  be  idiOpathic  or  symptomatic, 
the  stomach  is  sure  to  possess  great  acidity — to  destroy  this  is 
essential,  both  for  its  alleviation  and  cure. 

636.  Magnesia  should,  therefore,  be  freely  prescribed  ;  lime- 
water  and  milk  should  also  be  given,  particularly  where  the 
eruption  has  continued   several  days.     A  milk  diet  should  be 
adhered  to ;  and  if  no  fever  be  present,  chicken  water  and  beef 
tea  may  be  indulged  in. 

637.  It  is  common  in  this  disease  to  give  saline  purges;  but 
this  is  decidedly  injurious — there  is  no  purgative  so  certain  or 
proper,  as  magnesia,  or  magnesia  and  rhubarb.     It  is  also  com- 
mon to  permit  the   patient  to  take  lemonade ;  but  this  is  still 
worse — plain   water  or  toast  water,  not  too   cold,  are  the  best 
drinks.     Solid  food  should  be  avoided ;  as  should  damp  places, 
or  streams  of  cold  air. 


200  ERYSIPELAS. 

638.  To  relieve  the  excessive  itching,  the  patient  may  be 
liberally  dusted  with  well-toasted  rye  or  wheat  flour,  from  which 
much  relief  will  be  experienced.     In  the  chronic  form  of  this 
complaint,  we  have  found  a  persevering  use  of  small  doses  of 
Fowler's  mineral  solution  to   have  succeeded  in  every  case  in 
which  we  have  hitherto  tried  it. 

639.  A  very  interesting  case  of  chronic  urticaria  is  related  by 
Cazenave.     "  In  the  Hospital  of  St.  Louis,  in  a  patient  of  Mr. 
Biett's  wards,"  says  Mr.  C.,  "  we  have  seen  it,  (urticaria,)  ac- 
companying a  quotidian  intermitting  fever,  and  after  having 
lasted  for  four  years,  finally  induce  swellings  and  great  disten- 
tion,  ecchymoses,  ruptures,  and  ulcerations.  In  many  paroxysms 
it  was  accompanied  with  a  general  tumefaction ;  sometimes  to 
such  a  degree,  that  the  patient  was  nearly  suffocated ;  his  respi- 
ration was  hurried,  the  movement  of  the  thorax  very  slight,  the 
neck  swelled,  the  face  puffed  up,  and  of  a  violet  colour,  the  pul- 
sations of  the  heart  intermitting,  and  at  times  scarce  perceptible, 
and  death,  which  appeared  imminent,  only  prevented  by  large 
bleedings." 

640.  "  This  patient,  who  had  passed  through  several  hospitals, 
and  in  which  every  means  of  cure  had  failed,  was  at  last  restored 
to  health  by  the  use  of  Fowler's  solution."* 

641.  We  believe  we  were  the  first  to  recommend  Fowler's 
solution,  for  the  cure  of  chronic  urticaria. 

042.  Children  of  from  seven  to  fourteen  years  old,  may  take 
four  drops  every  morning,  noon,  and  evening,  in  sugar  and  wa- 
ter ;  or  should  this  sicken,  give  but  three. 


CHAPTER  VI. 

ERYSIPELAS. 

643.  THIS  disease  is  familiarly  called,  St.  Anthony's  fire;  it 
is  classed  among  the  exanthemata  by  nosological  writers,  and 
holds  in  the  public  estimation   a  distinguished  place,  from  its 
alleged  violence  and  danger. 

644.  It  shows  itself  upon  the  skin  in  one  or  more  places  at 
the  same  time,  and  to  a  greater  or  less  extent.     It  is  character- 
ized by  a  deep  red  colour,  heat,  and  swelling,  which  sometimes 
penetrates  through  the  corpus  mucosum  to  the  subcutaneous  cel- 

*  Prac.  Syn.  of  Cut.  Dis.  trans,  p.  65. 


ERYSIPELAS.  201 

lular  tissue;  the  redness  disappears  by  pressure,  but  quickly  re- 
turns when  this  is  taken  off.  It  may  attack  any  portion  of  the 
skin ;  though  it  is  more  common  for  it  to  select  the  extremities, 
and  face.* 

645.  This  affection  is  divided  into  several  varieties  by  wri- 
ters; thus  Mr.  Lawrence  divides  it  into  three;  namely,  the  sim- 
ple, the  oedematous,  and  the  phlegmonous.     Dr.   Good  recog- 
nises two,  the  local  and  erratic  erysipelas;  and  Cazenave  confines 
it  to  two,  namely,  erysipelas,  and  phlegmonous  erysipelas. 

646.  We  do   not  think  this  complaint  «ver  entitled  to  the 
distinction  of  phlegmonous ;  as  a  healthy  pus  has  never  been  seen 
in  any  instance  of  erysipelas;  nor  does  it  pursue  the  same  oscono- 
my  as  a  phlegmonous  inflammation  in  its  course  to  suppuration. 
One  of  the  provisions  of  the  system  in  a  genuine  phlegmon,  is 
the  swelling  which  takes  place  immediately  below  the  skin  ;  this 
becomes  very  hard  and  circumscribed  in  consequence  of  the  effu- 
sion of  coagulable  lymph,  which  is  intended  to  limit  the  extent 
of  the  suppurating  process,  and  to  prevent  the  diffusion  of  pus 
after  its  formation,  through  the  circumjacent  cellular  tissue.   Be- 
sides, erysipelas  has  but  little  disposition  to  suppurate,  unless  it 
penetrate  deep;  this  is  the  very  reverse  of  phlegmonous  inflam- 
mation, whether  deep-seated  or  not. 

647.  Now,  this  circumscription  never  takes  place  in  erysi- 
pelas; on  the  contrary,  the  fluid  formed  by  this  inflammation  is 
permitted  to  flow  where  it  list,  through  the  cellular  meshes;  and 
hence  the  extent  to  which  it  will  sometimes  spread  when  the 
complaint  is  very  active  and  extensive,  especially  when  the  part 
is  depending.     We  once  saw  it  in  a  child  extend  from  the  lower 
points  of  the  scapulas  to  the  base  of  the  sacrum. 

648.  Again,  in  a  genuine  phlegmonous  inflammation,  how- 
ever exalted  it  may  be,  the  part  occupied  by  its  action,  does  not 
vesicate ;  nor  is  the  tone  of  its  colour  like  that  of  erysipelas. 
Phlegmonous  inflammation  may  proceed  gradually  from  a  deep- 
seated  part  until  it  arrive  at  the  skin;  and  when  it  penetrates  this, 
H  may  be  at  first  seen  perhaps  as  a  slight  blush,  and  confined  to 

*  It  is  asserted  by  Dr.  Gregory,  that  "the  genuine  inflammation  of  the  skin 
has  peculiar  characters,  which  have  acquired  for  it  the  name  of  erythematous, 
or  more  properly,  of  erysipelatous  inflammation."  Why  this  is  advanced,  we 
are  at  a  loss  to  understand  exactly;  since  so  many  exceptions  are  constantly 
presenting  themselves.  For  the  skin  is  equally  liable  to  phlegmon,  as  to  ery- 
sipelas, and  between  these  two  inflammations  there  is  much  difference  both  in 
phenomena,  and  terminations;  for  even  when  both  resolve,  there  is  a  distinc- 
tion. Phlegmon,  when  it  disappears  by  resolution,  departs  without  leaving 
any  evidence  of  injury  to  the  cuticular  surface;  whereas  erysipelas  desquamates. 
Phlegmon,  when  it  terminates  by  suppuration  upon  any  but  a  secreting  sur- 
face, is  by  the  formation  of  an  abscess,  defined  or  limited;  erysipelas  ends  in 
vesicles,  phlyctenee,  and  in  the  formation  of  a  bloody  sanies. 

26 


202  ERYSIPELAS. 

a  small  point,  but  it  soon  extends  itself,  until  it  may  occupy  a 
large  surface,  and  be  of  an  intense  red.  Yet  it  does  not  vesicate 
nor  assume  the  yellowish  hue  of  erysipelas.  Erysipelas  almost 
always  commences  on  the  surface  first,  and  then  penetrates. 

649.  Mr.  Lawrence  says,  "the  pain,  (in  erysipelas,)  is  not  so 
intense  and  unremitting  as  in  phlegmon,  nor. is  it  attended  by 
throbbing."*      Does  this  not  prove  a  difference  of  character  in 
the  two  inflammations?  since  either  will  proceed  to  its  peculiar 
mode  of  suppurating,  but  are  perhaps  never  convertible ;  and 
consequently  the  difference  in  phenomena  in  this  process  cannot 
depend  upon  the  degree  of  inflammation,  but  to  a  specific  mode 
of  action;  and  this  will  constitute  an  essential  difference  in  these 
phlogoses.     It  is  therefore,  we  think,  a  great  misnomer,  to  call 
a  certain  stage  of  erysipelas,  for  it  is  nothing  more,  phlegmonous ; 
since  it  has  no  other  affinity  to  it,  than  it  has  to  all  the  other 
phlegmasia. 

650.  Besides,  erysipelas  it  is  contended  by  many,  is  conta- 
gious; Dr.  Wells  has  adduced  a  number  of  facts  upon  this  sub- 
ject, the  force  of  which  seems  to  have  produced  conviction  on  the 
mind  of  Dr.  Good;  though  they  do  not  appear  so  conclusive  to 
us.    And  agreeably  to  Willan,  erysipelas  may  be  communicated 
by  inoculation  ;  but  no  one  has  ever  pretended  that  a  phleg- 
monous inflammation  has  been  propagated  by  the  same  means. 

651.  The  character  of  its  terminations  is  also  different  from 
the  phlegmonous  inflammation  ;  on  the  surface,  vesicles,  bullae, 
or  phlyctense  form,  containing  a  fluid  of  a  pale  watery  or  straw 
colour,  or  a  bloody  sanies,  and  the  whole  part  affected  by  this 
inflammation,  when  severe,  is  particularly  disposed  to  end  in 
gangrene.     Besides,  Dr.  Parr  declares  it  to  have  been  epidemic. 
We  are  therefore  led  to  the  belief,  that  this  inflammation  is  pe- 
culiar, if  not  sui  generis,  especially  when  we    consider  with 
what  rapidity  it  runs  on  to  its  own  particular  modes  of  termi- 
nation. 

652.  The  erysipelas  of  Cazenave,  the  simple  of  Lawrence, 
and  the  local  of  Good,  more  frequently  selects  the  face  for  its, 
seat  than  any  other  portion  of  the  body.     This  seems  to  be  ad- 
mitted by  almost  all  the  writers  upon  this  disease  ;  indeed  this 
is  so  obviously  the  case  in  its  idiopathic  form,  that  Mr.  Arnott 
proposes  "that  the  term  erysipelas  be  restricted  to  that  febrile 
affection  of  the  system,  accompanied  with  inflammation  of  the 
integuments  of  the  face,  to  which  it  has  been  most  usually  ap- 
plied, and  that,  until  we  have  better  evidence  for  so  doing,  the 
expressions,  'erysipelas,'  and  'erysipelatous,'  should  not  be  ap- 
plied to  affections  of  the  skin  in  other  parts  of  the  body."     He 

*  Med.  Chirurg.  Trans.  Vol.  XIV.  p.  3. 


ERYSIPELAS.  203 

looks  upon  erysipelas  of  the  face  as  a  peculiar  affection;  and  that 
it  should  be  distinguished  from  other  inflammations  of  the  skin 
by  a  distinct  name.  Because  it  is  preceded  and  accompanied 
by  fever;  by  affections  of  the  sensorium;  by  its  having  a  deter- 
minate course,  and  by  its  being  probably  caused  by  contagion.* 

653.  It  is  almost  always,  when  it  is  of  any  extent,  ushered  in 
by  chilliness,  lassitude,  and  pain. 

654.  Heat  alternates  with  chilliness,  and  the  pain  is  confined 
very  much  to  the  head  and  neck.     After  these  symptoms  have 
continued  with  more  or  less  frequency  or  force,  for  twenty-four, 
and  eight  and  forty  hours,  the  inflammation  shows  itself  upon 
one  side  of  the  face,  the  cheek,  or  immediately  across  the  nose. 
A  burning,  and  an  itching,  is  for  the  most  part  first  felt  in  the 
spot  selected  for  its  attack;  and  its  approach  is  perhaps  hastened 
by  scratching  the  part. 

655.  The  redness  is  sometimes  very  intense;  at  others  less 
so;  but  it  can  always  be  displaced  by  the  pressure  of  the  finger, 
though  it  quickly  returns  upon  its  being  removed.     Vesicles  or 
bullae  now  appear,  filled  with  a  clear  watery  fluid;   these  gra- 
dually assume  a  yeljowish  colour,  which  soon  yield,  and  permit 
the  fluid  to  escape.     More  or  less  swelling  always  attends  this 
inflammation;  and  this  is  sometimes  excessive;   when  so,  it  is 
almost  always  accompanied  with  considerable  fever  and  deli- 
rium.    And  in  this  respect  it  may  be  said  to  differ  widely  from 
a  phlegmonous  inflammation,  if  this  be  even  more  extensive,  and 
very  much  more  painful.   We  have  seen  however  this  complaint 
when  not  extensive,  and  where  the  vesication  was  very  limited, 
unattended  by  fever;  but  this  is  rare.     Mr.  Lawrence  says,  "  the 
neighbouring  absorbent  glands  are  frequently  inflamed,  and  red 
streaks  are  seen  leading  towards  them."  p.  5.     This  we  have 
never  witnessed. 

656.  Sometimes,  both  sides  of  the  face  may  be  occupied  by 
erysipelas  at  the  same  time;  at  others  they  are  successive.  When 
but  one  side  is  the  seat  of  this  affection,  a  line  of  demarcation  is 
drawn  from  the  forehead  to  the  chin.     This  separation  of  the 
sound  from  the  diseased  part,  is  also  another  characteristic  of  the 
erysipelatous  inflammation,  of  which  we  have  no  example  that 
we  recollect,  in  the  phlegmonous. 

657.  The  febrile  symptoms  terminate  from  the  eighth  to  the 
tenth  day;  about  this  period,  or  sometimes  sooner,  the  inflam- 
mation changes  to  a  yellowish  or  brown  colour;  after  this  the 
surface  becomes  dry,  and  the  cuticle  is  thrown  off.    This  disease 
however  is  oftentimes  treacherous;  for  after  raising  an  expecta- 
tion that  it  had  taken  its  leave,  it  suddenly,  and  perhaps  as  vio- 
lently, returns  to  continue  some  days  longer.     When  the  extre- 

*  Lend.  Med.  and  Phys.  Journ.  Vol.  LVII.  p.  210. 


204  ERYSIPELAS. 

mitics  are  the  seat  of  this  complaint,  the  constitutional  symptoms 
are  less  violent;  and  it  runs  its  course  generally  more  rapidly, 
and  desquamation  follows  sooner. 

658.  The  erratic  nature  of  this  inflammation  is  known  to  all 
observers;  and  this  property  may  also  serve  to  confirm  the  opi- 
nion that  its  character  and  nature  is  peculiar.     It  wanders  more 
in  children,  we  think,  than  in  the  adult;  and  more  frequently 
proves  fatal  in  the  former  than  with  the  latter;  especially  under 
particular  circumstances,  as  in  ill-ventilated  apartments,  or  in 
crowded  hospitals.    Indeed,  Dr.  Underwood  says  he  has  not  met 
with  this  disease  often,  except  in  lying-in  hospitals.     Its  ordi- 
nary time  for  attack  in  such  situations,  is  generally  a  few  days 
after  birth — and  some  have  said,  never  after  the  month.     But 
Dr.  Underwood  declares  this  not  to  be  the  case;  in  private  prac- 
tice we  have  seen  it  very  much  later. 

659.  Dr.  Good  seems  however  unwilling  to  admit  this  affec- 
tion in  children  to  be  a  genuine  erysipelas;  he  says, "  what  how- 
ever is  usually  called  the  infantile  erysipelas,  is  more  commonly 
a  variety  of  gangrenous  erythema,  produced,  in  many  instances, 
by  want  of  cleanliness,  pure  air,  and  nutritive  food."51      We  are 
disposed  to  believe  this  to  be  a  distinction  without  a  difference. 
Nor  do  we  think  in  a  practical  point  of  view,  that  any  thing  is 
gained  by  this  multiplication  of  species  and  varieties.  We  are  of 
opinion,  that  an  erythematous  inflammation,t  of  sufficient  force 
to  produce  vesicles,  may  justly  be  called  erysipelas;  as  the  va- 
riation in  phenomena,  in  the  species,  and  varieties  of  these  sup- 
posed different  diseases,  prove  them  to  be  virtually  but  one  dis- 
ease, modified  by  the  force  of  the  remote  causes,  constitution,  or 
other  contingent  circumstances.     Thus  the  erythema  gangreno- 
sum,J  and  the  erysipelas  erraticum,§  of  Good,  are  but  one  and 
the  same  disease. 

*  Study  of  Med.  Vol.  II.  p.  409. 

•j-  "  Erythema — Red,  glabrous,  tumid  fulness  of  the  integuments;  disappear- 
ing on  pressure;  pain  burning;  inflammation  ulcerative;  termination  in  cuticu- 
lar  scales,  or  vesicles;  occasionally  in  gangrene."  Good,  p.  200.  Let  this  de- 
finition be  compared  with  the  histories  of  "  gangrenous  erythema"  and  the 
"  erratic  erysipelas,"  and  but  little  difference  will  be  perceived  in  their  cha- 
racters; and  that  little  will  perhaps  be  found  to  consist,  more  in  accidental  cir- 
cumstances than  in  essential  qualities. 

"  There  is  certainly  a  considerable  difference  between  a  pimple  and  a  boil, 
and  between  erythema  in  the  face,  and  erysipelas.  The  difference,  however, 
is  only  in  degree." — Philip  on  Symptomatic  Fever,  p.  39. 

t  "The  gangrenous  erythema,  is  a  frequent  companion  of  debilitated  or  re- 
laxed constitutions,  but  is  mostly  to  be  met  with  in  advanced  life,  or  weakly 
adolescence,  or  in  infancy;  and  particularly  where,  in  old  age,  the  constitution 
has  been  broken  down  by  habits  of  intemperance  and  excess;  the  circulation 
is  languid,  and  the  blood  even  in  the  arteries  assumes  a  venous  appearance." — 
Good's  Study  of  Medicine,  Vol.  II.  p.  207. 

§  "  The  inflammatory  blush  soon  assumes  a  livid  hue,  and  is  sometimes  co- 
vered with,  or  surrounded  by  petechize;  the  cuticle  is  separated  to  a  consi- 


ERYSIPELAS.  205 

660.  Nor  can  we  see  any  just  cause,  for  the  species  into 
which  erysipelas  is  divided — for  essentially  it  is  one  and  the 
same  disease ;  unless  it  may  serve  to  abridge  the  history  of  this 
complaint,  and  more  clearly  point  out  the  indications  which  may 
arise  from  the  several  conditions  in  which  it  may  exhibit  itself. 
For  the  several  forms  of  erysipelas  are  like  the  several  forms  of 
gout. — but  gout  is  nevertheless  gout. 

661.  Now  the  common  location  for  gout,  is,  the  foot — yet  it 
frequently  strays  to  other  parts;  but  it  is  still  gout;  it  does  not 
become  a  new  disease ;  for  wherever  situated,  the  action  excited, 
and  by  which  it  manifests  itself  in  the  new  part,  is  precisely  the 
same ;  and  if  curable,  the  same  remedies  would  reach  it  in  one 
spot,  as  well  as  in  another,  and  this,  under  all  its  modifications; 
for  of  this  it  is  susceptible,  in  proportion  as  the  nature  and  force 
of  the  remote  causes  may  be,  and  as  the  difference  of  constitu- 
tions may  exist.     Now,  this  erratic  disposition  of  gout,  is  really 
and  truly,  a  part  of  its  character ;  and  which  it  displays  when- 
ever circumstances  invite  to  it.     So  it  is  with  erysipelas;  it  will 
be  either  stationary,  or  it  may  wander — but  to  wherever  it  flies 
it  is  still  the  same  disease,  to  all  intents  and  purposes;  differing 
in  nothing,  but  its  seat,  and  the  consequences  that  the  part  last 
selected,  may  impose  upon  it. 

662.  Dr.  Good  says  that  "  the  local  erysipelas  generally  ex- 
hibits itself  on  one  side  of  the  face,  or  on  some  one  of  the  limbs." 
"  In  the  erratic,  the  complaint  usually,  and  particularly  in  adults, 
begins  its  attack  in  the  face,  and  spreads  in  succession  to  the  ex- 
tremities." In  what  essential  does  the  latter  differ  from  the  for- 
mer? in  none;  nor  does  the  distinction  lead  to  the  smallest  prac- 
tical good — for  it  is  altogether  dependent  upon  the  condition  of 
the  system,  whether  erysipelas  shall  be  stationary  or  fugitive ; 
for  that  which  is  stationary  at  this  moment,  may  be  erratic  the 
next ;  and  this  is  one  of  the  absolute  characters  of  the  disease. 

663.  So  long  then,  according  to  Dr.   Good,  as  the  inflam- 
mation continues  without  changing  its  seat,  it  is  the  "  local  ery- 
sipelas;"* and  when  it  wanders,  it  is  the  "  erratic  erysipelas;"! 

derable  extent  from  the  cutis,  breaks,  and  exposes  a  foul  and  ulcerating  sur- 
face, that  almost  immediately  passes  into  gangrene.  In  some  instances,  never- 
theless, these  cutaneous  efflorescences  are  probably  accompanied  by  a  true  erysipe- 
latous  fever."  We  would  now  ask,  can  an  "  erysipelatous  fever"  attend  any 
other  disease  than  itself?  for  it  would  be  idle  to  attempt  to  separate  an  "  erysi- 
pelatous fever,"  from  the  peculiar  inflammation  called  erysipelas. — Ib.  p.  408. 

*  "  Local  erysipelas — limited  to  a  particular  part;  the  cuticle  raised  into  nu- 
merous, aggregate,  distinct  cells;  or  the  cells  running  into  one  or  more  blebs 
or  large  blisters." 

f  "  Erratic  erysipelas — travelling  in  successive  patches  from  part  to  part;  the 
earlier  patches  declining  as  new  ones  make  their  appearance." — Good's  Study 
of  Med.  Vol.  II.  p.  407  and  408. 

"  Erratic  erysipelas— instead  of  passing  through  its  various  stages  where  it 


206  ERYSIPELAS. 

but  is  there  any  essential  difference  in  the  characters  of  the  two 
forms?  or  in  other  words,  is  there  a  species  of  this  disease,  which 
will  always  shift  its  ground  ;  and  is  there  another,  that  will  never 
do  so,  but  always,  and  under  all  circumstances,  remain  station- 
ary? Certainly  there  is  not — then  there  is  but  one  erysipelas, 
and  the  variety  that  may  be  observed  in  its  primary  appear- 
ances, its  progress,  its  ultimate  appearances,  and  its  terminations, 
depends  upon  the  body  it  infests,  and  not  upon  a  difference  in  the 
disease  itself. 

664.  When  the  erysipelatous  inflammation  penetrates  the  skin 
and  attacks  the  cellular  membrane,  (the  phlegmonous  erysipelas 
of  authors,)  it  for  the  most  part  becomes  from  its  extent,  a  very 
serious  disease,  as  its  limits  cannot  always  be  restricted.     This 
seerns  to  be  more  particularly  the  case  when  the  extremities  are 
the  seat  of  this  affection,  unless  it  should  be  confined,  as  some- 
times happens,  to  one  spot. 

665.  The  symptoms  of  this  form  of  erysipelas,  are  always 
more  violent  than  when  the  inflammation  has  not  penetrated  the 
rete  mucosum.     But  the  force  of  the  symptoms  will  necessarily 
vary,  as  the  disease  may  have  penetrated  to  a  greater  or  less 
depth,  the  extent  of  surface  it  may  occupy,  and  the  nature  of  the 
tissue  it  may  come  in  contact  with. 

666.  Should  the  disease  persevere  beyond  the  sixth  or  eighth 
day,  without  terminating  in  resolution,  suppuration  generally 
takes  place;  this  is  announced  by  a  diminution  of  the  burning 
pain  to  which  the  part  had  been  subject,  and  a  throbbing  sensa- 
tion takes  the  place  of  it ;  the  redness  diminishes;  chilliness ;  and 
matter  or  pus  is  discharged  perhaps,  accompanied  with  portions 
of  dead  cellular  membrane.  When  very  large  portions  of  the  cel- 
lular tissue  is  involved  in  this  inflammation,  delirium  with  very 
severe  pain  is  frequently  experienced.     The  part  is  very  red, 
and  the  slightest  pressure  gives  excessive  pain.     Fever  is  aug- 
mented; the  pulse  is  corded  and  frequent;  thirst  excessive; 
tongue  dry,  though  the  skin  is  sometimes  very  moist. 

667.  In  these  cases  resolution  is  scarcely  to  be  looked  for, 
though  the  treatment  may  have  been  vigorous,  proper,  and  in- 
dustriously pursued.  Suppuration  is  at  hand,  and  though  the  ex- 
ternal inflammation  appears  to  be  abated,  yet  the  swelling  in- 
creases; for  oedema,  to  a  greater  or  less  extent,  is  now  added  to 
the  other  evils.  The  matter  is  not  always  discharged  by  ulcera- 

was  first  developed,  it  may  successively  attack  different  parts  of  the  body,  and 
disappear  from  that  which  was  first  affected.  At  other  times  it  gradually  ex- 
tends over  a  greater  surface,  without  disappearing  from  its  original  point  of  at- 
tack, so  as  in  some  rare  instances,  to  cover  the  whole  body  at  the  same  mo- 
ment. In  certain  cases  it  suddenly  disappears,  and  attacks  another  spot,  leav- 
ing no  other  traces  than  a  slight  desquamation." — Cazenave,  p.  33. 


ERYSIPELAS.  207 

tlon,  and  may  therefore  remain  for  a  long  time  within  its  cavi- 
ties, and  thus  augmenting  symptoms  already  sufficiently  severe. 
When  the  matter  insinuates  itself  as  far  as,  or  commences  at  a 
fascia,  the  pain  oftentimes  becomes  intolerable,  and  the  patient 
would  soon  die  from  irritation,  were  artificial  means  not  resorted 
to,  to  give  it  vent. 

668.  Mr.  Lawrence  says,  "  the  skin  and  the  cellular  sub- 
stances are  the  seat  of  this  inflammation,  which,  in  examination 
after  death,  is  generally  found  not  to  extend  beneath  the  fascia. 
I  have  observed  that  the  cellular  texture  connecting  the  adipose 
membrane  to  the  fasciae  or  muscles,  suppurates  and  sloughs  more 
readily  than  the  adipose  substance  itself.  Mortification  frequent- 
ly occurs  in  the  former  when  the  latter  is  still  quite  healthy,  or 
at  least  only  affected  by  vascular  distention."     "  Mr.  Hutchin- 
son  speaks  of  the  'aponeuroses  of  the  muscles,'  and  the  '  aponeu- 
rotic  expansion,7  being  the  principal  seat  of  the  disease;  and  he 
adds,  he  is  persuaded  it  is  *  confined  chiefly  to  membranous  parts, 
such  as  the  aponeurotic  expansions,  skin,  sheaths  of  tendons, 
muscles,  &c.'  If,  which  is  doubtful,  Mr.  H.  means  that  the  fas- 
ciae or  aponeuroses  properly  so  called,  are  the  seat,  or  the  prin- 
cipal seat  of  the  disease,  I  cannot  agree  with  him,  having  always 
found  them  unaffected  in  examinations  after  death,  and  seen  no 
symptoms  referable  to  such  inflammation  during  life."  p.  15. 

669.  "  A  consideration  of  the  origin,  development,  and  ef- 
fects of  erysipelas,  of  all  its  phenomena,  whether  local  or  gene- 
ral, leads  us  irresistibly  to  the  conclusion  that  the  nature  of  the 
affection  is  inflammatory.     In  its  four  leading  characters  of  red- 
ness, swelling,  heat,  and  pain,  and  in  its  effects  of  effusion,  sup- 
puration, and  sloughing,  it  agrees  with  what  is  called  common 
or  phlegmonous  inflammation;  while  the  general  disturbance,  pre- 
ceding and  accompanying  the  local  affection,  is  exactly  alike  in 
the  two  cases.    Erysipelas  then,  is  merely  a  particular  modifica- 
tion of  cutaneous,  or  cutaneous  and  cellular  inflammation.   If  we 
were  to  class  these  according  to  their  natural  affinities,  we  should 
place  erysipelas  between  the  exanthemata,  and  phlegmon.     It  is 
less  diffused  than  the  former,  not  so  circumscribed  as  the  latter. 
The  exanthemata  are  confined  to  the  skin ;  erysipelas  affects  both 
skin  and  cellular  structure;  while  phlegmon  has  its  original  seat 
in  the  latter,  the  skin  being  secondarily  involved."  p.  18.   Not- 
withstanding this  attempt  to  identify  the  phlegmonous  with  the 
erysipelatous  inflammation,   we  remain    unconverted — we  are 
equally  persuaded  the  two  inflammations  are  essentially  differ- 
ent, as  many  of  their  phenomena  declare,  and  which  we  have  at- 
tempted to  prove.  We  are  of  opinion  that  the  only  division  that 
erysipelas  is  justly  susceptible  of,  is  into  the  superficial,  and  the 
deep-seated. 


208  ERYSIPELAS, 

670.  Indeed,  Mr.  Lawrence  himself,  notwithstanding  his  de- 
sire to  make  them  mere  "  degrees"  of  inflammation,  furnishes 
us  with  sufficient  data  to  prove  them  essentially  different.     He 
says,  "  the  difference  between  erysipelas  and  phlegmon,  how- 
ever, is  not  merely  in  the  original  seat  or  degree  of  the  dis- 
turbance; there  is  also  a  difference  in  kind.     We  may  indeed 
say  generally  that  phlegmon  is  a  more  violent  inflammation  than 
erysipelas,  but  sloughing  of  the  cellular  substance  is  more  fre- 
quent in  the  latter  than  in  the  former."  We  would  ask  whether 
these  facts  do  not  prove  their  difference  completely ;  first,  there 
is  a  difference  in  "  seat  and  degree;"  secondly,  in  kind;  third,  in 
result;  for  "sloughing  of  the  cellular  membrane  is  more  fre- 
quent" in  erysipelas  than  in  phlegmon.     This  last  is  a  curious 
fact,  and  seems  to  destroy  what  Mr.  L.  had  before  declared,  that 
erysipelas  was  a  less  violent  inflammation  than  the  phlegmon ; 
which  is  equal  to  declaring  that  the  lesser  degree  of  inflamma- 
tion will  kill  a  part  sooner  than  a  greater.     Besides,  phlegmon 
passes  through  various  stages  of  intensity,  yet  we  never  discover 
in  any  one  of  these  degrees,  the  erysipelatous  inflammation,  as 
an  usual  attendant  upon  its  progress,  which  should  happen  did 
they  differ  but  in  degree. 

671.  Again,  when  phlegmon  is  about  to  terminate  by  resolu- 
tion, it  must  be  by  a  gradual  abatement  of  its  inflammatory  force; 
a  minor  degree  of  inflammation,  or  that  degree  which  should 
constitute  erysipelas,  were  they  but  degrees  of  inflammation,* 
must  necessarily  arrive ;  but  this  never  happens — for  if  it  did,  it 
would  be  unsafe  ever  to  attempt  its  resolution ;  since  erysipelas, 
agreeably  to  this  doctrine,  must  necessarily  supervene.     Phleg- 
mon, therefore,  according  to  the  views  of  Mr.  L.  should  in  its 
progress  as  well  as  on  its  decline,  become  erysipelas.     Now,  is 
this  agreeably  to  fact?    Indeed,  were  this  doctrine  true,  phleg- 
mon should  never  exhibit  any  other  phenomena  than  erysipelas; 
it  should  never,  or  at  least  very  rarely,  have  characters  of  its 
own,  if  degree  alone  made  the  difference. 

672.  Were  this  true,  Mr.  L.  would  never  have  had  it  in  his 
power  to  declare,  that,  "the  most  striking  and  important  dis- 
tinction between  the  two  affections  is  that  inflammation  is  con- 
fined to  one  spot  in  phlegmon,  and  is  distinctly  circumscribed 
in  its  seat,  while  it  is  diffused  in  erysipelas,  and  spreads  with- 
out limit.     This  difference  seems  to  depend  on  the  adhesive 
character  of  the  inflammatory  process  in  the  former;  the  substance 
called    coagulating,   coagulable,   or  organizable   lymph   effused 

*  Mr.  Lawrence  says,  "  as  erythema,  simple  erysipelas,  and  phlegmonous 
erysipelas  are  merely  three  degrees  of  the  same  affection,  they  ought  never  to 
be  separated  in  our  classification."  p.  30.  Yet  we  shall  see  presently,  that  he 
abandons  this  division. 


ERYSIPELAS.  209 

round  the  inflamed  part,  forms  a  boundary  between  it  and  the 
sound  portion,  which  is  altogether  wanting  in  erysipelas."  And 
on  what  does  this  depend ;  upon  the  intensity  of  the  inflamma- 
tion ?  Is  an  exalted  degree  of  inflammation  more  favourable  to 
the  effusion  of  coagulating  lymph,  than  a  milder?  Yet  this  more 
benign  form,  kills  parts  more  certainly,  than  the  more  violent, 
agreeably  to  this — is  this  natural  ?  He  adds,  "  in  the  latter  the 
effusion  is  altogether  serous ;  hence,  when  matter  is  formed,  it  is 
not  confined  to  one  spot,  but  becomes  extensively  diffused  in  the 
cellular  tissue.  We  cannot  at  present  explain  the  cause  of  this 
difference;  that  is,  we  do  not  know  how  it  happens  that  coagu- 
lating lymph  is  poured  out  in  the  one  case,  and  serum  in  the 
other."  No,  we  cannot  explain  it — we  only  have  to  acknow- 
ledge the  fact,  that  every  distinct  inflammation  has  its  own  ha- 
bits, if  we  may  so  term  it ;  and  that  these  differences  of  habits 
constitute  the  specific  differences  of  inflammation.  No  one  can 
explain,  why  one  inflammation  shall  produce  the  matter  of  small- 
pox, another  of  cow-pox,  &c.  yet  this  happens,  not  from  the  de- 
gree of  the  respective  inflammation,  but  upon  the  peculiar  and 
distinct  character  of  the  inflammation — yet  each  of  these  inflam- 
mations have  "the  four  leading  characters  of  redness,  swelling, 
heat,  and  pain,"  which  it  may  be  perceived  are  not  sufficient  to 
explain  the  difference  in  the  phenomena  of  the  several  inflam- 
mations. 

673.  But  Mr.  L.  appears  immediately  after  to  abandon  the 
notion  of  "degree"  constituting  the  difference  between  phlegmon 
and  erysipelas,  and  acknowledges,  tacitly  at  least,  there  is  a  dif- 
ferent mode  of  action  in  the  various  inflammations,  and  this  is 
all  we  contend  for,  since  this  constitutes  the  essential  difference 
between  inflammations,  and  consequently  between  phlegmon  and 
erysipelas.  He  confesses,  "  we  are  equally  ignorant  of  the  es- 
sential nature  of  many  other  modifications  of  inflammation,  which 
are  yet  obviously  distinct.  No  one  could  overlook  the  differ- 
ences between  inflammation  of  the  finger  from  a  wound,  that  of 
a  whitlow,  of  chilblain,  of  erysipelas,  of  gout ;  yet  who  could  ex- 
plain the  differences  of  vascular  action  which  causes  these  dis- 
tinctions?" pp.  15,  16,  17,  18,  19.  If  it  be  confessed  there  is  a 
difference  in  "vascular  action,"  in  the  several  inflammations, 
then  a  difference  in  "  vascular  action"  must  constitute  the  differ- 
ence of  inflammation.  How  is  a  difference  of  "  vascular  action" 
proved,  but  by  the  phenomena  it  exhibits;  if  this  be  true,  there 
must  necessarily  be  an  essential  difference  between  the  erysipe- 
latous,  and  the  phlegmonous  inflammation,  as  their  phenomena 
differ  as  widely  as  that  of  small-pox  from  measles.  From  these 
considerations  we  think  it  wrong  ever  to  call  any  variety  of 
erysipelas,  phlegmonous. 

27 


210  ERYSIPELAS. 

674.  The  mode  of  treating  this  state  of  erysipelas,  properly 
belongs  to  surgery;  and  the  best  mode  of  employing  its  aid,  is  a 
much  mooted  point  at  this  moment*  The  dispute  upon  this  sub- 
ject, is  carried  on  with  an  unjustifiable,  as  well  as  an  injurious 
acrimony;  and  while  the  disputants  are  exercising  against  each 
other  every  kind  of  vituperation,  the  profession  is  suffering  in 
its  dignity  by  their  unnecessary  warmth. 

675.  Agreeably  to  Mr.  Hutchinson,  the  erysipelas  phlegmo- 
nodes  is  a  disease  of  common  occurrence  in  the  British  navy;  it 
attacks  the  more  condensed  or  aponeurotic  muscular  tissue,  though 
it  may  primarily  affect  the  skin.     When  pus  is  formed,  it  is  be- 
neath these  aponeuroses,  which  it  destroys  rapidly.     It  some- 
times affects  the  periosteum,  which  it  completely  detaches  from 
the  bone  itself. 

676.  It  would  seem,  that  the  anatomical  characters  of  erysi- 
pelas are  neither  extensive,  nor  very  interesting,  according  to 
Cazenave.     He  says,  "in  cases  of  severe  erysipelas,  not  only 
are  traces  of  inflammation  of  the  skin  discoverable,  but  the  sub- 
cutaneous cellular  tissue  is  found  very  friable,  and  infiltrated 
with  pus,  which  is  in  many  cases  collected  in  particular  spots." 

677.  "When  death  has  taken  place  suddenly  from  violent 
cerebral  affection,  no  appreciable  pathological  lesions  are  disco- 
verable.    At  other  times,  diseases,  either  of  the  lungs,  or  the 
alimentary  canal,  are  met  with,  whose  existence  had  never  been 
suspected."  p.  37. 

678.  The  causes  of  erysipelas,  may  be  the  same  as  those,  that 
cause  any  other  inflammation.    Over-stimulation  of  any  kind;  as 
too  high  living;  the  too  free  use  of  ardent  spirits;  suppressed 
evacuations;  punctured  or  other  wounds;  sudden  application  of 
cold  when  the  body  is  heated;  irritants  applied  to  the  skin,  as 
mustard,  spirit  of  turpentine,  horse-raddish,  garlic,  &c.  It  some- 
times arises  from  a  deranged  condition  of  the  biliary  and  diges- 
tive organs,  and  thus  becomes  what  Desault  calls  the  bilious 
erysipelas  ;  it  is  then  sympathetic. 

679.  Females  with  delicate  skins  are  more  liable  to  it  than 
dark-complexioned  women,  especially  about  the  period  of  pu- 
berty, and  at  the  cessation  of  the  menses.     Women  who  have 
borne  many  children,  and  particularly  such,  as  were  liable  to 
oedematous  swellings  during  their  pregnancies;  and  those  of  very 
costive  habits,  and  sour  stomachs.    Men  are  less  liable  than  wo- 
men.    Children,  whether  male  or  female,  when  crowded  in  ill- 
ventilated  hospitals,  are  particularly  obnoxious  to  it. 

680.  Certain  chronic  gastric  derangements,  are  accompanied 
with  erysipelas ;  and  acute  inflammations  of  this  organ,  has  also 
given  rise  to  it. 

*  See  Lancet. 


ERYSIPELAS.  211 

681.  The  symptoms  of  erysipelas  as  detailed  above,  will 
readily  distinguish  it  from  any  other  inflammatory  affection  of 
the  skin,  though  erythema  is  sometimes  mistaken  for  it  by  those, 
who  have  paid  but  little  attention  to  the  characters  of  diseases, 
or  who  are  in  the  habit  of  calling  every  efflorescence  of  the  skin, 
erysipelas. 

682.  But  little  inconvenience,  and  less  danger  attend  the  par- 
tial, and  mild  form  of  this  disease.     Not  so,  however,  is  the 
graver  cases  of  erysipelas ;  when  the  surface  it  occupies  is  consi- 
derable; when  it  quickly  vesicates,  and  its  colour  is  intense; 
when  much  fever  attends;  when  it  is  accompanied  by  delirium 
or  cerebral  congestion,  or  inflammation  of  the  stomach,  it  be- 
comes a  disease  of  imminent  danger.  It  is  especially  threatening 
to  such  as  may  have  oedematous  limbs,  or  anasarcous  swellings; 
or  when  it  accompanies  acute  diseases  of  the  chest,  stomach, 
liver,  or  intestines.     And  it  is  particularly  alarming,  when  the 
colour  of  the  inflammation  assumes  a  gangrenous  form  ;  as  this 
betrays  a  sinking  condition  of  the  system,  which  too  seldom  can 
be  restored. 

683.  Much  diversity  of  opinion  has  ever  existed  as  to  the  pro- 
per mode  of  treating  erysipelas.  This  has  arisen,  we  apprehend, 
more  from  the  expectation  of  finding  a  remedy,  that  shall  always 
arrest  this  disease  in  limine,  or  subdue  it,  at  any  stage  of  its  pro- 
gress, rather  than  from  our  not  possessing  means  suitable  to  the 
degree  of  its  intensity,  and  by  which,  its  force  may  be  diminish- 
ed, and  its  danger  lessened.     It  will  at  once  present  itself  as  a 
truth,  that  the  expectation  of  discovering  a  specific  for  this  dis- 
ease would  be  futile.    For  erysipelas,  is  like  all  the  rest  of  acute 
diseases,  in  having  various  stages  and  degrees  of  intensity;  and 
in  presenting  ever-varying  phenomena,  as  constitution,  age,  re- 
mote causes,  exciting  causes,  &c.  may  differ.     It  has  also,  like 
some  other  fevers,  the  misfortune  to  have  attached  to  it,  one  ge- 
nerally governing  or  prevailing  type,  by  most  of  the  writers 
upon  this  subject.     For  by  almost  all,  it  is  considered  as  a  dis- 
ease of  debility ;  and  that  it  must  be  treated  by  tonics  and  stimu- 
lants, both  internally  and  externally,  under  all  circumstances. 
Others  condemn  this  practice,  as  highly  injurious,  and  propose 
an  opposite  mode  of  treatment,  through  all  its  stages,  but  which 
is  not  less  at  variance  with  the  occasional  character  of  this  dis- 
ease— the  latter,  upon  the  whole,  is  the  safer  plan,  if  either  be 
implicitly  relied  upon. 

684.  Mr.  Lawrence,  whose  experience  has  been  both  ample 
and  successful,  says  upon  this  point,  "  although  erysipelas  in  all 
its  forms,  is  a  disease  of  frequent  occurrence,  and  comes  daily 
under  the  observation  of  the  physician  and  surgeon,  great  differ- 
ence of  opinion  still  prevails  respecting  its  nature  and  manage- 


212  ERYSIPELAS. 

ment  Regarding  it  as  an  affection  essentially  inflammatory, 
some  adopt  the  antiphlogistic  plan,  including  general  and  local 
bleeding  ;  while  others,  conceiving  that  the  part,  the  constitu- 
tion, or  both,  are  in  a  state  of  debility,  endeavour  to  remove 
this  by  the  free  use  of  stimulants  and  tonics,  more  especially  by 
bark,  ammonia,  and  wine.  The  former  appears  to  me  the  cor- 
rect view  and  practice ;  I  accordingly  consider  the  latter  notion 
completely  erroneous,  and  the  treatment  founded  on  it,  not  only 
inappropriate,  but  injurious."* 

685.  Thus  Dr.  Underwood  declares  bark  to  be  the  best  con- 
stitutional remedy,  and  saturnine  and  camphorated  medicaments 
the  best  local  applications;  while  Mr.  Burns  and  others  are  very 
doubtful  as  to  the  propriety  of  using  the  bark,  though  he  agrees 
with  Dr.  Garthshore,  that  camphorated  spirit  is  the  best  remedy 
from  first  to  last.     In  all  these  varying  directions  for  the  treat- 
ment of  erysipelas,  it  will  be  perceived,  that  there  is  a  total 
abandonment  of  governing  principles.     No  allowance  is  made 
for  its  being  idiopathic,  or  symptomatic;  for  its  extent ;  for  its 
location;  for  the  age  of  the  patient,  or  under  what  circumstances 
of  accommodation  he  may  be  in — yet  each  of  these  must  influ- 
ence, or  will  regulate,  the  treatment  to  a  certain  extent,  in  the 
hands  of  every  judicious  practitioner. 

686.  In  the  idiopathic  form,  when  the  extent  and  degree  of 
the  inflammation  is  not  great,  especially  if  the  patient  be  young, 
and  vigorous,  and  the  location,  is  any  other  part  than  the  extre- 
mities, and  this  attended   by  little  or  no  fever,  the  treatment 
should  not  be  the  same  as  where  the  reverse  of  all  this  obtains. 
For  in  the  first  instance,  an  antiphlogistic  regimen,  a  saline  ca- 
thartic, and  the  application  of  dry  flour,  with  confinement  to  the 
house,  will  frequently  relieve  this  inflammation.     Or,  under  the 
same  circumstances,  except  an  increase  in  the  severity  of  symp- 
toms, blood-letting  may  be  necessary.     But  when  the  contrary 
of  all  this  happens,  how  different  must  the  treatment  be.  Under 
these  opposite  conditions,  the  most  watchful  attention  may  be 
required,  that  depletion  may  not  be  carried  beyond  its  proper 
bounds ;  nay,  it  may  be  even  improper  to  draw  blood,  even  in 
small  quantities.     It  is  therefore  evident,  that  nothing  can  be 
more  uncertain,  if  it  even  fail  to  be  mischievous,  than  a  common 
routine  practice — or  in  other  words,  prescribing  for  the  name  of 
the  disease,  without  regarding  the  state  of  the  system.    We  will 
therefore  say  a  few  words  upon  the  subject  of  the  several  reme- 
dies most  commonly  employed  in  erysipelas. 

*  Medico-Chirurgical  Transactions,  Vol.  XIV.  p.  1. 


ERYSIPELAS.  213 


1.   Of  Bleeding. 

687.  In  treating  of  the  several  general  remedies  in  familiar 
use  in  erysipelas,  it  is  well  to  premise,  that  we  must  be  always 
understood  to  refer  to  the  idiopathic  form  of  this  complaint,  un- 
less the  contrary  be  expressed. 

688.  Of  the  use  of  the  remedy  now  under  consideration, 
much  diversity  of  opinion  has  existed  ;  while  some  laud  it  as 
highly  useful,  others  condemn  it  as  decidedly  injurious — now, 
perhaps  both  of  these  opinions  were  right,  as  regarded  the  prac- 
tice of  those  who  had  thus  treated  erysipelas;  because,  in  the 
first  instance,  it  was  resorted  to  under  circumstances  warranting 
its  employment;  while  in  the  second,  it  may  have  been  used, 
when  every  consideration  of  the  state  of  the  system  would  have 
forbidden  it.     And  these  opposite  conditions  of  the  system  may 
have  depended  upon  age,  period,  and  force  of  the  disease,  con- 
stitution, or  epidemic  influence.     That  bleeding  shall  be  useful, 
it  is  required  that  the  pulse  indicate  its  employment  by  its  force, 
frequency,  and  hardness ;  and  its  repetition   must  depend  upon 
the  continuance  of  sthenic  excitement.    Sydenham,  Vogel,  Cul- 
len,  and  Lawrence,  all  agree  that  the  blood  exhibits  when  drawn 
the  inflammatory  character. 

689.  Where  the  system  is  highly  excited,  especially  if  any 
viscera  become  secondarily  affected,  and  the  pulse  in  the  state 
just  described,  we  should  draw  blood,  be  the  period  of  the  dis- 
ease or  the  age  of  the  patient  what  they  may ;  with  this  reserve, 
however,  that  very  old  people,  or  very  young  children,  will  not 
bear  the  loss  of  the  same  quantity  of  blood  at  once,  though  they 
may  its  repetition,  with  decided  advantage — but  this,  the  pulse 
and  other  symptoms  must  determine.     We  are  persuaded,  that 
nothing  diminishes  the  excitement  of  the  system  so  promptly, 
or  so  efficaciously,  as  the  abstraction  of  blood,  whenever  the  dis- 
ease is  sudden  in  its  appearance,  rapid  in  its  progress,  and  threat- 
ening in  its  aspect;  for  if  the  excitement  of  the  system  be  not 
promptly  diminished,  the  inflammation  may  speedily  terminate 
in  gangrene. 

690.  We  are  aware  that  many  think  this  reduction  may  be 
more  safely,  and  as  speedily  effected  by  purging;  but  this  is  cer- 
tainly not  agreeable  to  our  experience,  though  we  place  much 
reliance  on  this  mode  of  evacuation,  where  the  system  is  not 
highly  irritated,  the  stomach  and  bowels  not  implicated,  and  the 
progress  of  the  disease  rapid. 

691.  The  disposition  manifested  by  the  aggravated  form  of 
erysipelas  in  hale  plethoric  habits,  to  terminate  in  gangrene, 
should  always  keep  us  upon  the  alert,  that  this  does  not  take 


214  ERYSIPELAS. 

place  by  employing  a  temporizing  plan,  or  from  an  apprehension 
that  depletion  will  but  hasten  this  event.*  It  is  true,  this  has 
been  asserted,  and  we  have  no  doubt  truly,  in  some  instances. 
But  does  it  follow  that  this  must  always  happen,  as  seems  to  be 
insinuated  by  some?  Certainly  not.  It  is  the  adoption  of  an  un- 
varying routine  practice,  and  not  a  discriminating  mode  of  treat- 
ment, that  has  led  to  this  erroneous  conclusion.  If  a  correct  esti- 
mate had  been  made  of  the  powers  of  the  system,  no  such  event 
could  have  happened  from  such  a  cause.  For  Mr.  Hunter  hap- 
pily thought  long  since,  that  gangrene  is  frequently  the  result  of 
excessive  action;  and  to  prevent  it  from  taking  place,  that  this 
excess  of  action  must  be  reduced;  and  that  for  this  purpose,  no- 
thing was  so  effectual  as  the  abstraction  of  blood.  Gangrene,  it 
is  true,  may  also  take  place,  from  a  loss  of  vascular  power ;  in 
which  case,  blood-letting  would  but  hasten  it;  but  let  it  be  re- 
membered, that  blood-letting  is  not  indicated  in  this  instance ; 
and  to  employ  it  would  be  an  error  of  judgment,  and  not  a  proof, 
as  is  assumed  by  such  as  have  committed  the  error,  that  blood- 
letting is  always,  or  even  most  commonly  improper,  in  erysipe- 
las. We  should  'therefore  always  draw  blood  when  the  force  of 
the  pulse  justifies  its  loss;  but  where  the  arterial  power  is  feeble 
and  languid,  it  should  never  be  resorted  to.  The  state  of  the 
pulse,  therefore,  must  ever  regulate  the  employment  of  blood- 
letting. 

2.    Of  Leeching. 

692.  The  propriety  of  using  leeches  in  erysipelatous  inflam- 
mation, is  even  more  doubtful  than  blood-letting.     On  this  part 
of  practice,  the  experience  of  this  country  is  perhaps  not  very 
ample,  since  so  much  is  feared  from  the  bite  of  the  leech  itself, 
that  they  are  rarely  resorted  to.     But  if  we  appeal  to  the  expe- 
rience of  the  continent  of  Europe,  and  particularly  France,  we 
shall  find  sufficient  evidence  of  their  usefulness,  to  justify  their 
employment  here.     Indeed,  Dr.  Neil  has  furnished  us  with  se- 
veral well-marked  cases  of  erysipelas,  in  which  leeching  was  a 
part  of  the  treatment,  and  in  which  they  appear  to  have  render- 
ed very  important  aid;  and  as  far  as  these  cases  go,  seem  to  esta- 
blish both  their  utility  and  safety. 

693.  Leeching  in  erysipelas  must  be  directed  by  the  same 
general  rules  as  govern  it  on  other  occasions  ;  namely,  after  the 
pulse  has  been  sufficiently  reduced  by  bleeding  from  the  arm,  if 

*  Dr.  Fordyce  says,  "  there  are  many  practitioners  in  this  country  who  still 
adhere  to  the  treatment  of  erysipelatous  inflammation  and  those  of  the  mucous 
membrane,  when  pure,  by  bleeding  and  other  evacuations,  which  Ihave  always 
found  hurtful" — Transactions  for  the  Improvement,  &c.  Vol.  1.  p.  293. 


ERYSIPELAS.  215 

the  state  of  the  system  had  required  it,  and  to  have  a  sufficient 
number  applied  to  make  a  decided  impression  upon  the  parts 
surrounding  that  to  which  they  have  been  applied.  The  propriety 
of  ordering  them  upon  the  inflamed  surface  is  perhaps  not  alto- 
gether established ;  at  least  we  have  never  pursued  it  ourselves, 
having  always  preferred  their  being  attached  some  distance  from 
the  diseased  spot.  We  believe  the  method  recommended  by 
Broussais  to  be  still  better  ;  namely,  having  them  spread  over  a 
considerable  surface  two  or  three  inches  from  the  affected  part. 
It  has  been  feared  that  leeching  might  produce  metastasis ;  but 
Broussais  entertains  no  such  apprehension.  And  a  reference  to 
Dr.  Neil's  cases  will  abate  our  fears,  when  these  animals  are  ap- 
plied to  the  diseased  surface. 

694.  Perhaps  it  might  furnish  some  practical  guide  for  the 
use  of  leeches,  did  we  attend  to  the  exciting  cause  of  erysipelas; 
thus,  if  it  followed  any  lesion  of  the  skin,  it  might  not  always 
be  considered  as  absolutely  necessary  to  have  recourse  to  them, 
unless  the  inflammation  were  extensive  and  threatening;  in  which 
case,  it  might  be  best  to  brave  the  consequences  of  the  bites  of 
the  leeches,  rather  than  to  encounter  the  consequences  of  an  ex- 
tensive and  destructive  inflammation. 

3.  Purging. 

695.  In  cases  of   pure  idiopathic  erysipelas,  the  utility  of 
purging  in  young  and  vigorous  habits,  cannot  be  questioned; 
nor  is  it  doubtful  to  a  certain  extent  in  aged  and  debilitated  con- 
stitutions, when  the  bowels  are  costive  and  very  tardy.     We 
therefore  never  hesitate  to  give  saline  purgatives  under  the  first 
circumstances;  but  we  prefer  the  castor  oil,  or  small,  but  repeat- 
ed doses  of  calomel  in  the  latter,  when  the  stomach  will  not  re- 
ceive the  oil.     We  also  give  calomel  to  very  young  children  in 
preference  to  the  saline  purgatives,  as  they  are  very  difficult  to 
administer  in  any  profitable  quantity. 

696.  The  utility  of  purgatives  is  perhaps  most  evident  in 
the  cases  in  which  erysipelas  attacks  the  face  and  head;  as  in  these 
cases,  delirium  seems  to  more  certainly  attend,  than  when  the 
inflammation  is  located  on  the  body  or  extremities;  and  free  dis- 
charges from  the  bowels,  appears  very  constantly  to  relieve  the 
brain,  when  in  a  state  either  of  congestion  or  of  inflammation. 

697.  When,  however,  erysipelas  is  purely  sympathetic,  the 
propriety  of  purging  must  be  determined  by  the  nature  of  the 
disease,  of  which  it  has  become  a  symptom — thus,  we  should 
forbear  active  purging,  when  gastric  or  intestinal  irritation  were 
present;  and  it  certainly  would  avail  but  little,  when  a  pneumo- 
nic disease,  was  the  original  affection;  for,  as  the  lungs  possess  a 


216  ERYSIPELAS. 

circulation  proper  to  themselves,  they  are  comparatively  but 
little  influenced  by  operations  upon  the  intestinal  canal.  But  in 
every  condition  or  state  of  erysipelas,  the  bowels  should  not  be 
permitted  to  remain  confined ;  the  proper  mode  of  obviating  this, 
either  by  gentle  laxatives,  or  by  mild  enemata,  must  be  left  to 
the  judgment  of  the  physician. 

4.  Blisters. 

698.  We  believe  that  Ambrose  Par6  was  the  first  to  employ 
blisters  upon  the  inflamed  surface  in  erysipelas ;  but  the  practice, 
if  it  ever  was  current,  soon  fell  into  disuse,  and  would  perhaps 
have  remained  so,  but  for  the  happy  revival  of  it  by  Dr.  Phy- 
sick.     Preposterous  as  this  remedy  may  appear  at  first  sight,  it 
is  one,  nevertheless,  of  the  greatest  efficacy  and  certainty,  when 
the  spot  for  its  application  will  permit  its  use. 

699.  When  the  application  of  a  blister  is  determined  on,  the 
plaster  must  be  of  such  a  size  as  will  rest  with  certainty  upon 
the  surrounding  portions  of  the  sound  skin.  When  this  becomes 
well  vesicated,  the  plaster  is  to  be  removed,  and  the  part  treat- 
ed, as  if  it  were  a  common  blister.     It  is,  however,  essential  to 
the  success  of  this  remedy,  that  the  precaution  just  suggested,  of 
making  the  plaster  of  such  size  as  shall  occupy  portions  of  the 
sound  skin,  be  strictly  adhered  to. 

700.  In  idiopathic,  as  well  as  in  symptomatic  erysipelas,  the 
effect  of  a  blister  is  sometimes  truly  surprising ;  and,  whether 
either  of  these  be  looked  upon  as  simple,  or  phlegmonous,  the 
utility  of  the  blister  is  equally  obvious,  and  should  therefore 
never  be  neglected  when  the  location  of  the  inflammation  will 
permit  its  application.      We  have  sometimes  surrounded,  in- 
stead of  covering  the  diseased  surface,  with  the  happiest  effects ; 
and  we  would  advise  this  method,  when  the  cuticle  has  pretty 
generally  separated  from  the  skin,  and  the  inflammation  con- 
tinues to  progress. 

701.  Mr.  Lawrence  informs  us,  p.  61,  that  "the  application 
of  blisters  to  the  inflamed  surface,  employed  in  France,  has  been 
sanctioned  by  the  high  authority  of  Dupuytren.     The  phlegmo- 
nous, and  the  erratic  species  of  the  complaint,  more  especially 
the  latter,  have  been  thus  treated."     Rayer  and  Sanson  speak 
unfavourably  of  the  practice.   Mr.  Lawrence  says/"  I  have  tried 
this  treatment  three  or  four  times  in  simple  erysipelas  of  the  ex- 
tremities, applying  the  blister  on  the  boundary  of  the  inflamed 
and  sound  parts,  so  as  to  cover  an  equal  portion  of  each.     The 
inflammation  stopped  in  these  instances ;  but  as  other  means  were 
employed  at  the  same  time,  I  could  not  determine  how  much  of 
the  benefit  was  due  to  the  blister,  which,  however,  did  not  pro- 


ERYSIPELAS.  217 

duce  suppuration,  nor  any  other  unpleasant  effect."  Mr.  Hutch- 
inson  speaks  favourably  of  the  effects  of  blistering  in  one  case — 
it  seems  to  be  the  only  one  in  which  he  ever  saw  this  remedy 
employed. 

5.  Mercurial  Ointment. 

702.  It  does  not  unfrequently  happen,  that  the  seat  of  inflam- 
mation is  such,  as  to  prevent  the  application  of  a  blister.  Under 
such  circumstances,  we  have  frequently  experienced  the  most 
decided  and  prompt  advantage  from  this  ointment,  and  did  it  not 
sometimes  salivate,  it  might  be  looked  upon  as  one  of  the  most 
certain  of  the  external  applications.     But  notwithstanding  this 
obvious,  and  serious  disadvantage  in  some  instances,  there  are 
others,  in  which  it  should  not  be  regarded  ;  for  it  is  of  much  less 
consequence  than  the  formation  of  large  abscesses,  and  extensive 
sloughings,  to  which  this  disease  so  frequently  tends,  especially 
in  hospital  practice,  and  in  enfeebled  constitutions.     In  every 
threatening  case  of  this  kind,  we  think  we  derived  the  greatest 
benefit  from  first  blistering  the  part,  and  then  dressing  it  with 
mercurial  ointment;  and  notwithstanding  a  very  large  surface 
was  for  a  number  of  days  covered  with  this  ointment,  no  saliva- 
tion followed  its  use,  though  the  amendment  was  much  more 
rapid  than  the  extent  of  the  disease  would  have  led  us  to  antici- 
pate— but  it  must  be  confessed,  in  two  other  instances,  and  these 
of  minor  consideration,  this  unpleasant  consequence  followed, 
though  not  severely  in  either. 

703.  We  use  the  ointment  in  different  manners  in  the  several 
conditions  of  the  inflamed  part.  First,  when  the  part  is  inflamed, 
but  not  vesicated,  we  cause  the  whole  of  the  inflamed  surface, 
together  with  the  surrounding  portions  of  the  sound  skin,  to  be 
kept  constantly  covered  with  the  ointment,  which  is  to  be  wash- 
ed off  every  twelve  hours,  and  fresh  ointment  made  to  supply  its 
place — fine  soap  and  tepid  water  is  the  best  things  to  remove  the 
encrusted  ointment. 

704.  Second.  Where  the  part  is  vesicated,  but  the  vesicles 
remain   unbroken.     In  this  case   we  cause  the  vesicles  to  be 
carefully  opened,  and  the  ointment  used  as  above  directed. 

705.  Third.   When  the  vesicles  have  opened  spontaneously, 
and  formed  a  crust  upon  the  surface,  but  where  the  inflammation 
extends  beyond  the  vesicated  part.     In  this  case  we  direct  the 
ointment  to  be  spread  upon  the  inflamed  surface  only,  and  upon 
the  contiguous  sound  skin. 

706.  Fourth.  Where  parts  have  proceeded  to  suppuration,  but 
portions  of  the  surrounding  skin  are  nevertheless  inflamed.     In 
this  case  we  open  the  collections  of  matter  as  early  as  possible, 
and  then  apply  the  ointment  to  the  margin  as  just  directed. 

28 


218  ERYSIPELAS. 

707.  Such  is  the  efficacy  of  this  application,  that  in  moderate 
cases  it  almost  immediately  arrests  the  further  progress  of  the 
disease.     In  this,  however,  all  do  not  agree ;  or  more  properly, 
perhaps,  it  is  denied  that  the  mercury  has  any  agency  in  the 
melioration  of  the  symptoms.  Dr.  Colhoun  says  this  application 
"is  valuable,  but  I  have  ascertained  its  usefulness  to  depend  upon 
the  lard,  and  not  upon  the  mercury."*  How  the  gentleman  dis- 
covered this,  we  are  not  informed  ;  but  it  certainly  does  not  cor- 
respond with  one  very  satisfactory  experiment  we  made  with  a 
view  to  test  this  assertion.     Mrs.  J.,  aged  thirty-five  years,  of 
nervous  temperament  and  sedentary  habits,  was  attacked  with 
an  erysipelatous  spot  upon  the  left  cheek,  about  the  size  of  a 
dollar.     This  was  first  perceived  in  the  evening,  and  by  next 
morning  it  had  spread  to  the  other  side  of  the  face,  completely 
involving  the  nose,  eyelids,  and  upper  lip.  This  appeared  a  most 
favourable  opportunity  to  test  the  comparative  efficacy  of  the 
mercurial  ointment  and  the  simple  lard.  We  accordingly  order- 
ed one  side  of  the  face  to  be  covered  with  the  mercurial  oint- 
ment, and  the  other  with  the  lard.     On  our  visit  next  day  we 
were  at  no  loss  to  determine  their  respective  merits;  but  we  per- 
severed in  the  applications,  and  at  the  end  of  five  days  the  part 
in  which  the  mercurial  ointment  was  used  did  not  vesicate,  and 
was  nearly  well,  while  that  on  which  the  lard  was  used  vesicated 
and  spread,  and  was  at  last  relieved  by  the  mercurial  ointment. 
This,  we  confess,  is  a  solitary  case ;  but  the  experiment  we  have 
no  doubt  would  very  constantly  result  in  the  same  way,  were  it 
repeated  ever  so  often. 

708.  To  us  it  is  a  matter  of  surprise,  that  it  should  have  been 
discovered  at  this  late  day,  that  all  the  writers  almost  who  have 
treated  of  erysipelas  for  at  least  a  century,  have  been  in  error 
respecting  the  use  of  fatty  substances  in  this  disease.     Heister 
forbids  them ;  he  says,  "  fat  and  oily  things  should  be  cautiously 
avoided  ;"t  and  we  could  quote  much  weighty  authority  against 
the  use  of  "  fat  and  oily  substances  alone" — but  they  may  be  all 
wrong,  and  the  point  must  be  settled  by  future  experience. 

6.   Of  Bark.\ 

709.  Of  this  substance  a  very  few  words  will  be  sufficient.  We 

•  Gregory's  Practice,  Vol.  I.  p.  515.  Note. 

f  Heister's  Works,  Vol.  I.  p.  194. 

t  "  Medical  practitioners  in  general  are  anxious  to  begin  the  strengthening 
plan;  they  seem  to  have  the  fear  of  debility  constantly  before  their  eyes,  and 
lose  no  time  in  directing  the  employment  of  bark,  and  recommending  animal 
food  with  beer  or  wine.  In  this  way  relapses  are  frequently  produced;  the  in- 
flammation and  fever  are  renewed,  further  local  mischief  is  caused,  and  reco- 
very is  retarded." — Lawrence,  on  the  Nature,  lie.  of  Erysipelas,  Med.  Chir. 
Transactions,  Vol.  XIV.  p.  59. 


ERYSIPELAS.  219 

have  never  employed  it  but  where  the  suppurating  surface  was 
large;  the  discharge  great,  and  of  an  unhealthy  quality.  In  such 
cases  the  bark  is  highly  useful  as  a  tonic,  but  not  as  a  specific,  in 
erysipelas.  It  will  perhaps  be  asked,  how  it  has  received  so 
many  encomiums  from  several  writers  in  this  complaint — the 
answer  we  believe  is  easy ;  it  has  been  resorted  to  when  the  cir- 
cumstances of  the  system  required  a  tonic  plan  of  treatment,  as 
has  been  partly  explained  already.  Or,  it  may  have  early  re- 
quired the  use  of  the  bark,  from  its  connexion  with  some  other 
disease,  in  which  the  state  of  the  system  needed  its  exhibition ; 
or  from  possessing  some  epidemic  peculiarity,  foreign  to  its  usual 
character.  In  a  word,  bark  has  no  other  pretension  to  efficacy 
in  erysipelas,  than  the  other  forms  of  phlegmasia. 

710.  As  a  general  rule  then,  in  the  treatment  of  erysipelas,  we 
must  constantly  endeavour  to  procure  resolution,  as  its  suppu- 
rating is  always  attended  with  more  or  less  inconvenience,  if  not 
with  danger.     And  that  when  this  disease  produces  great  cere- 
bral disturbance,  the  condition  of  the  brain  and  its  appendages 
should  elicit  our  attention;  for  then  the  erysipelas  becomes  of 
secondary  consideration. 

711.  When  this  affection  is  symptomatic,  the  disease  by  which 
it  was  produced  should  constantly  claim  our  attention ;  for  it 
would  be  vain  to  attempt  the  destruction  of  erysipelas,  while  the 
original  complaint  continued  in  full  force.  Yet  the  external  means 
recommended  above  may  be  resorted  to  with  advantage,  provided 
we  do  not  lose  sight  of  its  cause. 

7.  Incisions  and  Puncturing. 

712.  Mr.  Lawrence  recommends  in  warm  terms,  incisions  in 
the  phlegmonous  erysipelas ;  he  declares  "  the  most  powerful 
means  of  arresting  the  complaint  is  by  making  incisions  through 
the  inflamed  skin  and  the  subjacent  adipose  and  cellular  textures, 
which  are  the  seat  of  disease.  These  incisions  are  followed  very 
quickly,  and  sometimes  almost  instantaneously,  by  relief,  and 
the  cessation  of  the  pain  and  tension;  and  this  alleviation  of  the 
local  suffering  is  accompanied  by  a  corresponding  interruption 
of  the  inflammation,  whether  it  be  in  the  stage  of  effusion,  or  in 
the  more  advanced  stage  of  suppuration  and  sloughing.  The  red- 
ness of  the  skin  is  visibly  diminished  during  the  flow  of  blood 
from  the  incisions;  in  twenty-four  hours  it  has  usually  disappear- 
ed, and  the  skin  itself  is  found  wrinkled  from  the  diminution  of 
the  general  inflammatory  tension." 

713.  "The  immediate  relief,  although  very  desirable  to  the 
patient,  is  however  of  less  consequence  than  the  decided  influ- 
ence of  the  practice  in  preventing  the  further  progress  of  the  dis- 


220  ERYSIPELAS. 

order ;  and  this  important  result  has  never  failed  to  occur,  within 
my  experience,  when  the  case  has  been  a  proper  one  for  the 
practice,  and  the  state  of  the  patient  has  admitted  of  its  being 
fairly  tried."  "  The  treatment  by  incisions  is  suited  to  various 
stages  of  the  complaint;  but  it  is  employed  to  greatest  advantage 
at  the  beginning,  since  it  prevents  the  further  extension  of  in- 
flammation, and  the  occurrence  of  suppuration  and  sloughing. 
The  redness  and  swelling  gradually  subside;  the  surface  of  the 
cut  granulates,  and  it  heals  rapidly.  At  a  more  advanced  period, 
the  incisions  limit  the  extent  of  suppuration  and  gangrene ;  and 
at  a  still  later  time,  they  afford  the  readiest  outlet  for  matter  and 
sloughs,  and  facilitate  the  commencement  and  progress  of  gra- 
nulation and  cicatrization.  When  the  matter  has  been  fully  dis- 
charged, and  the  sloughs,  whether  of  the  skin  or  cellular  mem- 
brane, have  separated,  a  healthy  granulating  surface  is  left,  and 
no  great  difficulty  is  experienced  in  effecting  cicatrization,  un- 
less the  destruction  of  the  skin  should  have  been  very  exten- 
sive, when  the  cicatrix  forms  slowly,  and  is  liable  to  give  way 
again." 

714.  "  To  preclude  the  possibility  of  misconception  on  a 
practical  point  of  so  much  importance,  I  beg  to  observe  that  I 
do  not  advise  incisions  in  erysipelas  generally,  but  confine  their 
employment  to  cases  of  the  phlegmonous  kind." 

715.  "The  limbs,   especially  the  lower,  are  the  most  fre- 
quent seat  of  the  affection,  which  is  at  least  very  uncommon  on 
the  trunk.*     After  the  incisions  have  been  made,  the  part  may 
be  covered  with  warm  fomentation  cloths  until  the  bleeding  has 
ceased,  when  a  warm  bread  and  milk  poultice  may  be  applied. 
If  discharge  should  not  soon  take  place  from  the  wound,  it  must 
be  dressed  under  the  poultice  with  the  yellow  basilicon   oint- 
ment, or  with  some  other  stimulant.     When   suppuration  has 
already  occurred,  the  matter  finds  a  free  discharge  at  the  inci- 
sion ;  large  portions  of  the  cellular  membrane  often  slough,  and 
come  away  with  copious  discharges  of  matter,  and  it  is  some- 
times necessary  to  extend  the  incision,  in  order  to  promote  their 
separation.   When  this  is  at  an  end,  and  more  particularly  when 
the  skin  has  been  extensively  detached  by  sloughing  of  the  cel- 
lular membrane,  pressure  by  bandage  is  very  serviceable  in  pro- 
moting the  healing  process." 

716.  "The  incisions,  when  made  during  the  existence  of 
active  inflammation,  are  followed  by  profuse  bleeding,  both  from 
arteries  and  veins,  which  probably  has  an  important  share  in  ar- 


•  We  might  insist  on  this  fact,  as  corroborative  of  the  distinct  and  indepen- 
dent natures  of  the  phlegmonous  and  erysipelatous  inflammations;  since  the 
"  trunk"  is  as  liable  to  phlegmon  as  the  extremities. 


ERYSIPELAS.  221 

resting  the  inflammatory  disturbance.  The  benefit,  however, 
cannot  wholly  be  ascribed  to  this  cause,  for  it  takes  place  even 
when  the  loss  of  blood  is  much  less;  and  it  is  so  immediate,  that 
we  cannot  refer  it  to  the  suppurative  process  which  afterwards 
occurs  in  the  surface  of  the  wound.  The  relief  has  been  ascribed 
to  the  removal  of  that  tension  which  always  exists  in  a  greater 
or  less  degree;  we  observe,  indeed,  that  the  edges  of  the  wound 
usually  gape  asunder,  and  that  the  surrounding  skin  not  only 
loses  its  deep  red  colour,  but  soon  becomes  wrinkled  on  the 
surface;  two  changes  which  sufficiently  explain  the  great  and 
sudden  benefit  usually  produced  by  the  incisions." 

717.  "As  the  free  bleeding  from  the  incisions  is  often  of 
great  advantage  in  relieving  the  overloaded  vessels,  and  arrest- 
ing the  inflammation,  it  need  not  be  checked,  so  long  as  the 
pulse  is  unaffected  by  the  loss  of  blood.     But  the  great  extent  to 
which  the  haemorrhage  may  proceed,  renders  it  necessary  that 
we  should  act  very  cautiously,  especially  in  elderly  persons,  or 
in  those  whose  strength  is  already  impaired  by  the  disease  or 
previous  treatment.     The  patient  should  be  carefully  watched  in 
such  cases,  until  the  bleeding  has  ceased.  Should  it  be  necessary 
to  stop  the  further  loss  of  blood,  this  may  be  readily  accomplish- 
ed by  tying  any  bleeding  vessels,  by  placing  the  limb  in  an  ele- 
vated position,  or  by  pressure." 

718.  "  The  incision  should  divide  the  skin  and  the  cellular 
texture  down  to  the  fascia;  it  is  not  necessary  to  penetrate  the 
latter.     A  double-edged  bistoury  is  the  most  convenient  instru- 
ment for  this  purpose.3'* 

719.  As  we  are  desirous  of  communicating  the  various  modes 
of  treating  this  formidable  disease  that  have  been  found  most 
successful,  we  are  certain  we  shall  not  be  blamed  for  furnishing 
the  above  long  extract,  as  well  as  laying  before  the  reader  the 
modes  pursued  by  Dr.  Dobson,  and  Mr.  A.  Copland  Hutchinson, 
both  men  of  distinguished  professional  reputation. 

720.  Dr.  Dobson  says,  "  in  regard  to  the  nature  of  the  ery- 
sipelas in  which  I  use  the  punctures,  I  answer  in  all  cases,  whe- 
ther simple,  traumatic,  or  phlegmonous;  the  number  of  punc- 
tures I  make  at  any  one  time,  varies  according  to  the  extent  of 
the  disease,  but  is  rarely  under  ten,  and  seldom  exceeding  fifty; 
the  depth  and  extent  of  each  puncture  vary  also,  according  to 
circumstances,  being  made  deeper  when  the  parts  are  more  tu- 
mid, but  more  superficial  when  the  tumefaction  is  not  so  great ; 
from  two  to  four-tenths  of  an  inch  may  however  be  considered 
the  proper  answer  to  that  part  of  your  inquiry.     I  repeat  the 

•  See  Observations  on  the  Nature  and  Treatment  of  Erysipelas,  by  W.  Law- 
rence, Esq.  Medico-Chirur.  Trans.  Vol.  XIV. 


222  ERYSIPELAS. 

punctures  to  the  number  and  extent  required,  mostly  twice  a 
day,  and  often  in  bad  cases,  three  or  four  times  in  the  twenty- 
four  hours,  and  in  the  whole  course  of  this  practice,  which  has 
often  been  resorted  to  by  me  in  several  hundred  cases,  having 
adopted  it  more  than  a  dozen  years  ago,  I  have  never  seen  any 
bad  consequence  resulting  from  its  employment.  The  quantity 
of  fluid,  (for  it  is  not  blood  alone,  but  blood  and  effused  serum,) 
which  these  punctures  discharge,  although  sometimes  consider- 
able, need  never  create  any  alarm,  for  however  freely  it  may 
flow  at  first,  it  gradually  diminishes,  and  soon  spontaneously 
ceases.  I  use  these  punctures  in  every  part  of  the  scalp  or  face, 
body  or  extremities,  and  never  more  freely  than  about  the  eye- 
lids, and  I  have  often  found  a  patient  with  both  eyes  closed, 
which  by  freely  puncturing  he  has  been  able  to  open  in  a  few 
minutes;  and  what  will  be  found  not  less  true,  than  it  may  ap- 
pear surprising,  these  punctures  mostly  heal  in  a  few  hours,  and 
never  entail  any  material  marks  upon  the  patient !" 

721.  "  Where  puncturing  has  been  practised  from  the  first 
appearance  of  the  disease,  suppuration  rarely  takes  place,  and  I 
have  always  observed  that  it  diminishes  the  extent  of  that  re- 
sult, even  in  those  cases  which  have  existed  for  some  days  be- 
fore it  has  been  resorted  to ;  but  when  matter  does  at  any  time 
form  under  the  skin,  I  let  it  out  without  delay  wherever  I  feel 
it;  but  I  think  in  those  cases  the  integuments  are  more  preserv- 
ed by  making  several  small  openings,  than  by  one  large  incision, 
and  the  matter  is  quite  as  well  evacuated."* 

722.  Mr.   Hutchinson  is  also  a  strong  advocate  for  free  in- 
cisions in  the  phlegmonous  erysipelas;  he  says,  "these  inci- 
sions may  be  made  about  an  inch  and  an  half  in  length,  from  two 
to  four  inches  apart,  and  varied  in  number  from  four  to  eighteen, 
according  to  the  extent  of  surface  the  disease  is  found  to  occupy." 
He  recommends  these  incisions  to  be  made  in  the  early  part  of 
this  disease  ;  declaring  they  prevent  extensive  suppuration,  and 
sloughing,  as  well  as  arrest  the  progress  of  the  disease.     In  this 
country,  this  mode  of  treating  erysipelas,  we  believe  has  riot 
been  attempted  to  any  extent;  but  we  are  of  opinion,  that  every 
reliance  is  to  be  placed  upon  these  operations,  as  their  authors 
are  men  of  the  highest  respectability.     The  practitioner  has  his 
choice  of  three  modes  of  operating,  when  the  disease  is  either 
too  extensive  or  too  violent  to  be  subdued  by  the  antiphlogistic 
mode  of  treatment,  or  by  the  other  means  recommended  as  ad- 
juvants to  this  plan. 

•  See  Letter  to  W.  Lawrence,  Esq.  F.  R.  S.  on  the  Treatment  of  Erysipe- 
las by  Numerous  Punctures  in  the  Affected  Part,  by  R.  Dobson,  M.  D.  &c. 


PSORA,  OR    ITCH.  223 


8.  External,  or  Local  Applications. 

723.  This  class  of  remedies  is  very  numerous,  but  very  in- 
significant, to  say  the  least  of  the  generality  of  them.  We  have 
but  little  opinion  of  them  if  we  except  blisters,  and  mercurial 
ointment.  In  the  early,  or  erythematous  stage,  if  we  may  so 
term  it,  we  have  thought  that  the  camphorated  spirit  has  been 
occasionally  useful,  but  never  efficacious  in  our  hands.  The  sa- 
turnine lotions  we  have  thought  decidedly  injurious.  Dry  flour 
has  frequently  relieved  the  itching  and  burning  when  it  has  been 
applied  before  vesication  had  taken  place ;  but  it  should  never  be 
used  after.  The  watery  solution  of  opium  is  highly  praised  by 
some,  but  of  this  we  have  no  experience.*  And  lately  Dr.  Fon- 
taneilles  has  recommended  a  solution  of  the  tartrite  of  antimony 
in  the  proportion  of  a  drachm  to  a  pint  of  water  as  very  effica- 
cious in  this  disease.  He  directs  no  precaution  against  its  ad- 
mission to  a  wounded  surface  when  inflamed.  He  also  com  mends 
it  in  pruritus,  dartres,  and  lumbago. 


CHAPTER  VII. 

PSORA,  OR  ITCH. 

724.  This  affection  may  be  considered  strictly,  cuticular ;  its 
rritation  never  rousing  the  circulating  system  into  action, 
however  extensive  the  surface  may  be,  that  is  infected.  It  is 
generally  communicated  by  infection;  and  the  virus  by  which  it 
communicates  itself,  is  supposed  by  many,  to  contain  animal- 
culae.  But  Dr.  Adams  in  his  treatise  upon  "Morbid  Poisons," 
strongly  inclines  to  a  disbelief  in  these  animals — nay,  in  a  dis- 
ease, with  which  he  compares  the  itch,  he  founds  one  of  his  dis- 
tinctions upon  the  vesicles  in  "  itch"  containing  no  worm;  while 
in  the  other,  they  were  palpable.  Contact,  or  even  wearing  a 
garment  after  an  infected  person,  is  generally  sufficient  to  com- 
municate the  disease.  It  is  however  declared  by  some,  that  the 
"  itch"  may  be  generated  by  impure  air,  unwholesome  food,  or 

•  This  solution  is  made  by  dissolving  four  grains  of  opium  in  eight  ounces  of 
water,  and  then  adding  ten  grains  of  the  acetate  of  lead;  the  part  is  to  be  kept 
constantly  moist  with  it.  Ur.  Peart  recommends  a  drachm  of  the  sub-carbo- 
nate of  ammonia,  and  as  much  superacetate  of  lead,  dissolved  in  a  pint  of 
rose  water. 


224  PSORA,  OR    ITCH. 

a  neglect  of  personal  cleanliness.  Location  is  even  said  to  ge- 
nerate it — hence,  the  cold  mountainous  districts  of  Scotland,  are 
charged  with  generating  and  perpetuating  it.  There  is  not  in 
our  opinion,  sufficient  evidence,  that  the  mere  absence  of  clean- 
liness will  produce  the  disease,  however  great  may  be  its  instru- 
mentality in  aggravating,  and  perpetuating  it. 

725.  This  disease  almost  always  first  shows  itself  in  places  in 
which  the  cuticle  is  not  very  dense — as  between  the  fingers,  the 
wrists,  the  bendings  of  the  arms,  the  hams,  &c.  The  first  symp- 
tom is  slight  vesications  or  pustules  upon  the  parts  just  indicated  ; 
this  is  soon  followed  by  intense  itching,  which,  when  indulged  in, 
breaks  the  little  vesicles,  and  spreads  the  contaminating  virus  to 
the  skin  immediately  around  them,  and  thus  extends  the  disease 
even  over  the  whole  body,  if  permitted  to  run  an  undisturbed 
course.     The  itching  is  most  troublesome  at  night,  after  the  pa- 
tient becomes  warm  in  bed;  a  circumstance  that  may  help  our 
diagnosis,  as  well  perhaps  as  offer  an  argument  in  favour  of  the 
animalcular  origin  of  this  disease.     For,  the  itching  must  neces- 
sarily be  owing  to  irritation ;  which  will  of  course  be  commensu- 
rate with  it;  while  the  irritation  may  depend  upon   an  increase 
of  vigour  in  the  animalculae,  from  the  additional  warmth  of  the 
bed-clothes,  &c. — hence,  perhaps  the  selection  of  such  parts  of 
the  body,  as  preserve  their  temperature,  the  most  uniformly — 
and  such  are  the  parts,  generally  infected,  by  itch. 

726.  Systematic  writers  make  several  varieties  of  itch  ;  as — 
PapulariSj  or  rank  itch.  —  Vesicularis,  or  watery  itch. — Pu- 
rulenta,  or  pocky  itch. — Complicata,  or  complicated  itch. — 
Exotica,  or  mangy  itch. 

727.  There  is  no  practical  benefit  to  be  derived  from  this 
enumeration ;  therefore,  we  shall  not  insist  upon  these  distinc- 
tions ;  especially,  as  Dr.  Good,  who  has  defined  each  with  some 
care,  assures  us,  "that  all  these  affections  are  not  distinct  spe- 
cies ;"  for  that,  "  under  different  conditions  of  the  skin,  every 
variety,  even  the  mangy  itch  itself,  will  produce  every  other  va- 
riety, while  all  of  them  coexist,  and  are  destroyed  by  the  same 
means."  Study  of  Med.  Vol.  IV.  p.  429. 

728.  This  disease  is  of  easy  management;  especially  in  the 
commencement,  and  where  its  localities  are  few,  and  small.   We 
have  very  often  removed  this  complaint,  particularly  when  con- 
fined to  the  hands  and  wrists,  by  the  following  solution: — 

B.   Hydrargyri  oxymurias, 

Muriat.  ammon.  aa.  gr.  x. 

Aq.  distillat.     -  -         ^ij.  f.  sol. 

The  pustules  or  little  sores,  are  to  be  washed  with  this  solution 
morning  and  evening,  until  irritation,  or  slight  inflammation,  is 


PSORA,  OR  ITCH.  225 

induced — then  desist  until  the  inflammation  goes  off;  and  if  the 
disease  be  not  cured,  let  the  application  be  renewed  under  the 
same  restriction,  until  it  disappear.  It  is  best  to  open  each  ve- 
sicle by  the  point  of  a  needle,  before  the  solution  is  applied.  It 
is  most  conveniently  applied  by  means  of  a  small  piece  of  fine 
sponge. 

729.  But  should  the  disease  be  more  extensive,  mercury  or 
sulphur  in  ointments,  had  best  be  used.     Mercury,  in  the  form 
of  the  white  precipitate,  where  secrecy  is  required,  is  perhaps 
the  most  certain,  and  convenient  mode  of  using  this  substance. 

R.  Hydrargyr.  praecip.  alb.  -   5ij- 

Ess.  Lemon.        ...  -   gut.  xl. 

Adeps  praeparat.  -   £ij.         M. 

The  parts  to  be  rubbed  with  this  ointment  for  three  successive 
nights — the  skin  must  then  be  well  washed  and  cleansed,  by  a 
pretty  strong  solution  of  soap  and  warm  water.  Should  the  disease 
not  be  removed,  let  the  ointment  be  repeated,  until  it  succeed. 
But  if  the  disease  be  inveterate  or  of  long  standing,  we  believe 
there  is  no  remedy  so  certain  as  sulphur  in  combination  with  the 
muriate  of  ammonia — this  has  never  failed  us,  however  exten- 
sive, or  of  how  long  a  standing  it  may  be.  It  very  rarely  re- 
quires more  than  two  applications  to  effect  a  cure. 

R.  Flor.  sulph. 

Pulv.  muriat.  ammon. 

01.  Menthae, 

Adeps  prseparat  -      ?iv.       M. 

The  whole  body  is  to  be  smeared  well  with  this  ointment  in  a 
warm  room  if  the  weather  be  cold,  just  before  going  to  bed,  and 
the  patient  to  sleep  with  the  ointment  upon  his  skin — in  the 
morning  it  is  to  be  entirely  discharged  from  the  skin  by  means 
of  soap  and  water.  The  patient  is  now  to  put  on  clothes  not 
used  previously;  and  must  not  be  allowed  to  sleep  in  the  sheets 
before  employed.  This  process  must  be  repeated  on  the  second 
night,  as  before  directed;  this  must  be  followed  by  liberal  ablutions 
next  morning,  with  the  same  attention  to  fresh  clothes.  We  have 
never  known  this  plan  to  fail.  In  the  ointment  just  recommend- 
ed, the  offensive  smell  of  the  sulphur  is  overpowered  by  the  oil 
of  mint. 

730.  Dr.  Jadelot  of  Paris  recommends  the  sulphuret  of  potass 
in  the  form  of  a  bath ;  to  be  repeated  daily  for  a  few  days.     He 
orders  four  or  five  ounces  of  this  substance  to  about  twenty  gal- 
lons of  water  heated  to  98°  Fahrenheit,  and  the  patient  placed  in 
it  for  a  short  time.     While  Dr.  Gale  lauds  fumigations,  prepared 
by  throwing  a  mixture  of  sulphur  (half  an  ounce)  and  nitre  (two 

29 


226  PHBENITIS. 

drachms)  upon  hot  coals  in  a  warming  pan,  and  used  in  the  or- 
dinary way  of  warming  a  bed.  The  patient  gets  into  bed  naked, 
and  the  fumes  are  carefully  kept  in  by  tucking  the  bed-clothes. 
This  must  be  repeated  nightly  for  a  week. 


CHAPTER  VIII. 

DISEASES  OF  THE  BRAIN  AND  SPINAL  MARROW. 
SECT.  I. — PHRENITIS. 

731.  By  this  we  understand  an  inflammation  of  the  brain  or 
of  its  appendages.      So  far  as  we  are  at  present  acquainted  with 
this  disease,  and  its  symptoms,  we  are  not  able  to  say  which  por- 
tion of  the  cerebral  system  is  particularly  affected,  though  post 
mortem  examination,  declares  that  either  the  substance  of  the 
brain,  or  its  coverings,  or  both  may  be  involved.     Much  pains 
has  been  taken  by  late  pathologists  to  distinguish  the  one  affec- 
tion from  the  other ;  and  some  have  thought  they  have  been  able 
to  do  so,  and  have  enumerated  a  number  of  symptoms,  which 
purport  to  point  out  the  particular  structure  that  is  affected  ;  but 
there  is  much  doubt  upon  this  point;  and  fortunately  in  a  practi- 
cal point  of  view,  it  is  of  very  little  importance,  since  the  know- 
ledge of  the  existence  of  either,  would  not  influence  our  thera- 
peutical views. 

732.  Thus  Dr.  Fordyce  says,  "if  the  meninges  are  affected, 
the  pain  is  acute ;  if  the  substance  only,  obtuse,  and  sometimes 
but  just  sensible."  Practice  of  Medicine.     Dr.  Cullen  observes, 
"I  am  here  as  in  other  analogous  cases,  of  opinion,  that  the 
symptoms  above  mentioned  of  an  acute  inflammation,  always 
mark  inflammations  of  membranous  parts ;  and  that  an  inflamma- 
tion of  parenchyma,  or  substance  of  viscera  exhibits,  at  least 
commonly,  a  more  chronic  inflammation."     There  is  much  rea- 
son to  challenge  the  truth  of  these  opinions;  they  certainly  fail 
in  pneumonia,  and  we  believe  we  could  prove  they  do  not  hold 
good  in  either  the  brain  or  its  appendages,  as  we  shall  have  oc- 
casion to  say  in  its  proper  place. 

733.  We  shall  therefore  comprehend  under  the  term  phrenitis 
the  inflammation  of  the  substance  of  the  brain,  or  that  of  its  ap- 
pendages, or  both  ;  as  it  is  extremely  doubtful  whether  we  are  in 
possession  of  any  pathognomonic  sign  for  either.     Mr.  Pinel* 

*  Nosographie,  Vol.  II.  p.  180. 


PHRENITIS.  227 

censures  Sauvages,  for  the  confident  manner  in  which  he  details 
the  symptoms  belonging  to  each  membrane  of  the  brain,  and  the 
brain  itself  when  labouring  under  inflammation.  He  declares 
this  decision  altogether  premature ;  and  thinks  with  our  present 
stock  of  knowledge,  we  have  no  right  to  make  a  distinction  be- 
tween the  one  part  and  the  other  when  in  a  state  of  phlogosis. 
We  are  decidedly  of  this  belief;  for  we  have  never  been  satisfied 
that  any  peculiar  cognizable  circumstance  marked  the  seat  of  the 
inflammation. 

734;  As  to  the  marks  laid  down  by  some  authors,  we  are  cer- 
tain they  cannot  be  relied  upon — more  especially  those  which 
consist  in  the  distinction  of  the  quality,  if  we  may  so  term  it,  of 
the  attending  pain.  Acute  and  obtuse  pain,  the  chief  distinctions, 
are  easily  confounded,  and  we  are  certain  they  cannot  be  relied 
uponj  for  what,  in  a  person  with  even  a  moderately  clear  intel- 
lect, would  be  called  acute,  might  by  another  receive  the  epithet, 
obtuse ;  and  it  becomes  still  more  uncertain,  when  the  operations 
of  the  mind  are  disturbed,  by  an  overwhelming  inflammation  of 
the  organ  of  intellect. 

735.  In  treating  this  subject,  we  shall  at  this  time  confine  the 
consideration  to  the  idiopathic  form  of  this  disease ;  at  least  as 
far  as  circumstances  will  permit  us  to  distinguish  it  from  the 
symptomatic.     At  the  bed-side  this  is  not  so  easy  as  it  might  at 
first  appear  to  be.     Acute  diseases  of  other  viscera  are  very  fre- 
quently attended   with   intellectual   derangement — dciirium    is 
common  to  most  fevers ;  the  stomach,  the  intestines,  the  liver, 
the  lungs,  when  inflamed,  may,  produce  severe  or  mild  mental 
aberrations.  In  one  of  the  most  furious  cases  of  delirium,  I  ever 
witnessed,  and  which  bore  the  most  unequivocal  marks  of  cere- 
bral inflammation,  Dr.  Physick  and  myself  found  the  brain  upon 
examination  to  be  healthy,  while  the  stomach  exhibited  the 
highest  grade  of  inflammation ;  while  on  the  other  hand,  Willis, 
Bonetus,  Sarcone,  &c.  have  observed  inflammations  of  the  brain, 
without  delirium  having  preceded  death.*     Stollt  has  seen  the 
brain  and  its  membranes,  inflamed,  gangrenous,  together  with 
abscesses,  in  idiopathic  phrenitis.     MorgagniJ  has  seen  a  true 
phrenitis,  without  leaving  any  marks  of  inflammation  in  either 
the  brain  or  its  appendages. 

736.  These  are  curious,  as  well  as  important  facts;  and  should 
teach  us  caution  in  deciding  upon  the  seat  of  a  disease,  especially 
where  the  body  may  be  inspected  after  death;  and  also  should 
convince  us,  that  there  are  no  absolutely  certain  signs  by  which 
the  condition  of  the  brain  or  of  its  appendages  can  be  recognised; 

•  Pinel.  Nosographie,  Vol.  II.  p.  183. 

*  Letter  VII.  Art.  VI. 


228  PHRENITIS. 

for  however  advantageous  a  distinction  might  prove,  it  can  rarely 
be  made,  but  by  opening  the  head. 

737.  The  predisposing  causes  of  phrenitis  are  pretty  generally 
the  same  as  those  which  give  rise  to  the  other  phlegmasiae.  The 
exciting  causes  may  be  insolation ;  immoderate  mental  excite- 
ment, as  anger;  the  too  free  use  of  ardent  spirits ;  errors  in  diet; 
metastases,  as  of  gout,  rheumatism,  erysipelas;  cuticular  affec- 
tions, &c.* 

738.  The  premonitory  signs  of  phrenitis,  will  vary  both  in  in- 
tensity and  duration,  as  the  susceptibility  of  the  body  may  be 
greater  or  less,  or  as  the  force  of  the  exciting  cause  may  be  stronger 
or  weaker,  or  perhaps  as  it  may  be  one  or  other  portion  of  the 
brain,  or  its  appendages  that  may  receive  the  shock,  and  perpe- 
tuate the  impression.    For  the  most  part  there  is  head-ache,  and 
its  seat  may  be  general,  or  confined ;  a  sense  of  fulness,  particu- 
larly if  the  head  be  placed  a  little  depending,  or  suddenly  moved; 
a  throbbing  within  the  cranium,  communicating  the  idea  that  the 
pulses  within  the  cranium  can  be  heard.   Disturbed  sleep ;  start- 
ings  ;  grinding  of  the  teeth ;  frightful  dreams ;  irascibility  ;  un- 
usual gaiety;  redness  of  the  eyes;  face  tumid  and  flushed;  easily 
shedding  tears,  or  perhaps  they  flow  involuntarily ;  sensation  of 
cold ;  extreme  sensibility  to  light  or  to  noise ;  bleeding  at  the 
nose ;  agitation  ;  limpid  urine  ;  costiveness,  &c. 

739.  In  the  idiopathic  form  of  phrenitis,  the  pulse  betrays  less 
disturbance  than  really  exists ;  and  this  circumstance  may  serve 
with  others  to  point  out  the  independent  nature  of  the  affection. 
For  when  this  disease  is  symptomatic,  the  pulse  always  partakes 
of  the  character  it  assumes  in  the  individual  inflammation  which 
preceded  the  affection  of  the  brain,  and  with  which  it  is  sympa- 
thizing. Dr.  Wilson  Philip  says,  and  in  this  we  fully  agree,  that 
"the  hardness  of  the  pulse  is  more  remarkable,  (in  phrenitis,) 
than  in  synocha ;  sometimes  it  is  both  small  and  hard,  and  some- 
times irregular;  the  pulse  in  synocha  is  always  strong,  full,  and 
regular."! 

740.  In  no  acute  disease  of  the  system,  is  there  less  evidence 
in  some  cases  of  local  disturbance,  than  in  inflammation  of  the 
appendages  of  the  brain,  or  of  even  the  substance  of  the  brain 
itself.  We  have  lately  witnessed  very  remarkable  derangements 
of  this  kind  in  two  children,  who  died  unquestionably  from  these 
affections,  though  in  one  the  disease  followed  a  mild  case  of  mea- 
sles, and  the  other  a  violent  attack  of  pneumonia.  In  neither  in- 
stance, was  there  the  slightest  delirium ;  in  one,  there  was  a 

•  We  do  not  enumerate  among  the  causes  of  phrenitis,  certain  mechanical 
impressions  or  forces,  such  as  blows,  falls,  or  wounds  of  various  kind,  as  the 
disease  arising  from  such  accidents,  properly  belongs  to  the  care  of  the  surgeon. 

•J-  Symptomatic  Fevers,  p.  81. 


PHRENITIS.  229 

slight  strabismus;  yet  in  both,  there  were  marks  of  high  previous 
inflammation.  In  one,  at  least  three  ounces  of  serum  escaped 
from  between  the  dura  mater  and  the  surface  of  the  brain;  the 
vessels  of  the  brain  itself  were  much  enlarged ;  and  its  substance 
somewhat  softened.  In  the  other,  there  was  less  serum,  but  a 
purulent  substance  spread  itself  over  the  whole  of  the  superior 
surface  of  the  brain,  dipping  between  its  hemispheres,  and  was 
even  found  at  its  base.  The  whole  mass  of  brain,  was  of  uncom- 
mon softness.  In  both  instances,  the  dura  mater  adhered  so 
firmly,  as  not  to  be  separated  without  tearing.  One  case  termi- 
nated by  convulsions ;  the  other  with  much  apparent  agony,  but 
with  perfect  consciousness. 

741.  Pinel  says,  "  that  coma  may  attend  a  true  inflammation 
of  the  brain,  without  being  preceded  by  phrenitis;  in  proof  of 
which  I  will  relate  two  instances  in  two  children,  one  aged  seven 
years  the  other  eleven.  On  examining  the  first,  the  tunica  arach- 
noides  was  found  thickened  in  several  places,  and  spread  over 
with  granulations;  it  was  red,  and  adhered  to  the  dura  mater, 
and  to  a  certain  extent,  a  layer  of  albuminous  matter  was  to  be 
seen.     In  the  other  child,  the  inflamed  condition  of  the  tunica 
arachnoides  was  equally  remarkable;  it  also  adhered  to  the  dura 
mater,  and  was  occupied  by  a  similar  coat  of  albuminous  matter. 
The  right  lateral  ventricle  was  distended  by  a  great  quantity  of 
serum."* 

742.  M.  Harpin  has  run  a  long  parallel  between  the  symp- 
toms of  phrenitis  and  cephalitis ;  to  which  the  author  of  the  ar- 
ticle "  Phrenitis,"  in  the  Diet,  des  Scien.  Med.   M.  Vaidy, 
makes  the  following  judicious  remarks:  "  After  reading  this  pa- 
rallel, nothing  appears  to  be  easier  than  to  distinguish  cephalitis 
from  phrenitis;  but  unfortunately  it  is  not  so  at  the  bed-side:  for 
there  is  no  characteristic  symptom  to  distinguish  these  affections 
from  each  other,  and  they  may  be  so  entirely  attended  with  the 
same  signs,  that  experienced  practitioners  have  mistaken  one  for 
the  other." 

743.  The  progress  of  this  affection  is  no  less  constant  than 
rapid ;  augmenting  in  intensity,  until  it  is  about  to  terminate  fa- 
vourably or  fatally.     It  has  however  its  moments  of  remission 
and  of  exacerbation,  like  any  other  phlegmasia;  and  these  may 
be  more  or  less  regular.     A  treacherous  calm  sometimes  takes 
place,  only  to  be  followed,  by  highly  exasperated  symptoms — 
even  furious  delirium.     And  such  is  the  severity  of  the  inflam- 
mation, and  the  importance  of  the  parts  involved  in  it,  that  it 
runs  its  course  in  a  few  days,  if  not  arrested  by  prompt,  and  pro- 
perly adapted  treatment. 

744.  It  has  always  been  looked  upon  as  very  difficult,  to  es- 

•  Nosographie,  Vol.  II.  p.  189. 


230  PHRENITIS. 

tablish  the  diagnosis  of  phrenitis;  especially  from  that  grade  of 
fever  called  synocha  or  inflammatory  fever.  This  difficulty  con- 
sists chiefly  in  the  want  of  pathognomonic  signs  for  phrenitis; 
and  from  synocha  almost  always  being  attended  by  delirium. 
This  however  would  not  create  much  embarrassment,  were  the 
views  taken  of  fever  by  Dr.  Clutterbuck  thoroughly  established, 
or  were  they  susceptible  of  it;  as  agreeably  to  him,  phrenitis  or 
inflammation  of  the  brain,  is  the  cause  of  fever,  and  consequently, 
it,  with  all  its  phenomena,  has  a  phlogosed  state  of  the  brain  or 
its  appendages  for  its  origin. 

745.  "  Sometimes  nausea  and  a  painful  sense  of  weight  in  the 
stomach  are  among  the  earliest  symptoms.     In  other  cases  the 
patient  is  attacked  with  vomiting,  or  complains  of  heartburn, 
and  griping  pains  in  the  bowels.     When  the  reader  reflects  on 
the  intimate  connexion  which  subsists  between  the  brain  and 
every  part  of  the  system,  he  will  not  be  surprised  to  find  the 
symptoms  attending  the  commencement  of  phrenitis  so  various, 
and  that  the  stomach  should  in  particular  suffer,  which  so  re- 
markably sympathizes  with  the  brain.     These  symptoms  assist 
in  forming  the  diagnosis  between  phrenitis  and  synocha."* 

746.  The  symptoms  just  enumerated  we  think  are  more  com- 
mon to  children  or  very  young  subjects, than  to  adults  and  elderly 
people.  We  have  seen  in  several  very  strongly-marked  cases  of 
this  kind,  in  each  of  which  the  disease  was  supposed  to  be  in  the 
stomach,  and  to  which  all  the  remedies  were  unavailingly  ad- 
dressed ;  the  post  mortem  examination  proved  the  seat  of  the 
disease  to  be  the  brain.     Perhaps  the  most  certain  diagnostic 
symptom  in  this  disease,  is  the  terrifying  intolerance  to  light, 
when  this  symptom  occurs,  for  it  is  not  always  present.     We 
have  seen  the  approach  of  a  candle  throw  a  child  nearly  into 
convulsions,  and  draw  from  it  the  most  importunate  supplica- 
tions to  have  it  immediately  removed.     Dr.  Philip  justly  ob- 
serves,  "  if  in  phrenitis  we  succeed  in  removing  the  delirium 
and  other  local  symptoms,  the  febrile  symptoms  in  general  soon 
abate ;  whereas,  in  synocha,  though  the  delirum  and  head-ache 
be  removed,  the  pulse  continues  frequent,  and  other  marks  of 
indisposition  remain  for  a  much  longer  time,  and  this  serves  to 
distinguish  the  two  diseases."! 

747.  "  The  eyes  are  incapable  of  bearing  the  light;  and  false 
vision,  particularly  that  termed  muscas  volitantes,  and  the  ap- 
pearance of  false  flashes  of  light  passing  before  the  eyes,  are  fre- 
quent symptoms.     The  hearing  is  often  so  acute,  that  the  least 
noise  is  intolerable ;  sometimes,  on  the  other  hand,  the  patient 
becomes  deaf;  and  the  deafness  Saalman  observes,  and  morbid 
acuteness,  now  and  then  alternate.  "J 

•  Philip  on  Symptomatic  fever,  p.  79.         f  Ib-  P-  W.          *  Ib.  p.  80. 


FHRENITIS.  231 

748.  "  As  the  organs  of  sense  are  not  frequently  deranged  in 
synocha,  the  foregoing  symptoms  further  assist  the  diagnosis  be- 
tween it  and  phrenitis."* 

749.  The  prognostic  in  this  disease  must  always  be  uncertain, 
if  not  always  unfavourable ;  for  when  we  consider  the  importance 
of  the  parts  involved  in  inflammation,  the  delicacy  of  their  struc- 
ture, the  great  quantity  of  blood  circulating  through  them,  and 
the  quantity  required  to  be  abstracted  from  the  system  in  gene- 
ral before  much  impression  can  be  made  upon  the  contents  of 
the  cranium,  and  the  changes  effected  in  the  remaining  portion 
of  blood,  by  the  capillaries  yielding  their  contents  to  the  larger 
vessels  after  very  large  quantities  have  been  abstracted,  we  shall 
cease  to  be  surprised  that  phrenitis  is  constantly  a  disease  of  dif- 
ficult management,  and  of  great  danger.     Yet  these  cases  are  not 
altogether   hopeless.      When  this  disease  supervenes  to  other 
affections  of  an  acute  kind,  as  gastritis,  enteritis,  &c.  the  prog- 
nostic is  almost  always  unfavourable,  as  we  have  two  seats  of 
inflammation  now  to  contend  with;  and  this  at  a  period  when 
the  recuperative  powers  of  the  system  are  on  the  wane,  if  not 
very  much  exhausted.     In  general,  the  risk  is  in  proportion  to 
the  violence  of  the  symptoms;  but  this  is  far  from  always  being 
the  case,  as  the  apparently  milder  forms  have  terminated  fatally, 
though  not  equally  rapidly.  We  have  already  declared,  that  this 
inflammation  terminates  sometimes  in  suppuration,  effusion,  and 
gangrene  ;  in  either  of  these,  the  case  must  be  hopeless,  though 
we  have  no  absolutely  certain  signs  that  determine  either  has 
taken  place,  though  either  may  be  suspected,  when  coma,  para- 
lysis, squinting,  or  convulsions  follow  the  more  acute  and  vio- 
lent symptoms.    Also,  when  the  skin  becomes  cold,  clammy,  or 
rigid;  the  pulse  creeping,  very  quick,  small  and  feeble;  respira- 
tion hurried;  preternaturally  slow,  laborious,  or  stertorous,  we 
may  look  upon  death  being  near  at  hand. 

750.  As  regards  the  alvine  excretions,  Dr.  Philip  says,  that 
"  instead  of  a  superabundance  of  bile,  there  is  sometimes  a  defi- 
ciency of  it,t  which  seems  to  afford  a  still  worse  prognosis.  The 
faeces  being  of  a  white  colour,  and  a  black  cloud  in  the  urine, 
are  regarded  by  Lobb  as  fatal  symptoms.     The  black  cloud  in 
the  urine  is  owing  to  an  admixture  of  blood."     "There  is  often 
a  remarkable  tendency  to  the  worst  species  of  haemorrhagy  to- 
wards the  fatal  termination  of  phrenitis."  p.  82. 

751.  On  the  other  hand,  we  may  regard  the  following  marks 
as  constituting  the  favourable  signs;  a  generally  diffused  warmth, 
without  rising  to  a  preternatural  heat ;  warm  and  extended  per- 
spiration; urine  depositing  a  sediment;  haemorrhage  from  the 

*  Philip  on  Symptomatic  fever,  p.  81. 

t  Desault  makes  a  bilious  species  of  phrenitis. 


232  PHRENITIS. 

uterus,  the  nose,  or  the  haemorrhoidal  vessels  in  the  more  ad- 
vanced period  of  the  disease ;  eruptions  upon  the  skin,  especially 
of  the  inflammatory  kind ;  the  pulse  becoming  more  voluminous, 
quicker,  or  less  frequent;  diminution  of  delirium  and  coma,  &c. 

752.  The  mode  of  treating  this  disease  can  almost  be  deduced 
from  its  history — it  is  essentially  an  inflammation  of  a  highly 
sensible  and  vascular  part,  the  organization  of  which  is  quickly 
liable  to  lesion,  from  causes  that  would  scarcely  disturb  some 
other  of  the  viscera.     It  must  be  evident  that  our  chief  reliance 
must  be  placed  upon  the  abstraction  of  blood;  and  this  will  em- 
brace both  general  and  local  blood-letting. 

753.  The  nearer  to  the  head  we  can  abstract  blood,  the  better  ; 
but  the  most  proper  place  cannot  always  be  commanded,  for  this 
would  be  the  jugular  vein.     There  is  much  difficulty  sometimes 
in  drawing  blood  from  the  neck — the  patient,  unless  it  be  a  child, 
will  not  always  submit  to  it,  if  he  be  even  in  his  senses  ;  and  if 
he  be  delirious,  it  is  almost  impracticable.    Hoffman  and  Cullen 
were  both  aware  of  the  advantages  that  would  result  from  draw- 
ing blood  so  directly,  and  at  the  same  time  so  suddenly  from  the 
diseased  part;  and  it  is  to  be  lamented,  that  their  directions  to 
this  effect  can  so  seldom  be  complied  with.     When,  however, 
this  can  be  done,  it  is  certainly  proper  in  violent  cases,  to  give 
the  jugular  the  preference.    It  nevertheless  excites  much  alarm, 
when  proposed,  though  there  is  neither  disadvantage  nor  danger, 
from  the  operation — we  have  repeatedly  performed  it  on  children 
for  convulsions,  with  the  happiest  results ;  nor  have  we  ever  wit- 
nessed any  inconvenience  from  after-bleeding,  as  might  reason- 
ably enough  be  expected.* 

754.  But  whether  we  select  the  jugular  vein,  or  take  the  arm, 
sufficient  quantity  of  blood  should  be  drawn  to  produce  a  most 
decided  impression  on  the  pulse;  nay,  even  to  syncope  would 
be  desirable  in  some  instances.    These  effects  are  best  secured  by 
placing  the  patient  in  an  erect  position,  and  drawing  the  blood 
from  a  large  orifice.   And  this  operation  must  be  repeated  as  often 
as  the  symptoms  and  state  of  the  pulse  demand  it.     In  this  re- 
spect, and  indeed  in  almost  all,  the  treatment  must  be  such  as  has 
been  directed  for  fever  of  a  high  grade.     And  it  must  be  borne 
in  mind,  that  we  have  other  resources  in  this  disease,  when  the 
diminished  force  of  the  pulse  might  not  justify  the  abstraction 
of  blood  from  the  arm.     The  application  of  leeches  behind  the 
ears,  and  angle  of  the  jaw,  or  to  the  temples  and  forehead,  will 
be  found  highly  useful  in  the  idiopathic  form  of  phrenitis ;  and 
if  sympathetic,  to  the  part  nearesi  to  the  affected  viscera.   If  it  be 
gastritis,  over  the  region  of  the  stomach,  &c. 

•  Larrey,  however,  makes  it  an  operation  of  difficulty  and  sometimes  of  dan- 
ger. We  have  never  observed  either  in  children,  and  when  the  spring  lancet 
has  been  used. 


PHRENITIS.  233 

755.  Cupping  may  also  be  had  recourse  to,  where  leeches  can- 
not be  commanded;  and  the  spots  selected  for  their  application, 
should  be  the  same  as  directed  for  the  leeches.     And  if  neither 
cupping  nor  leeching  can  be  done,  much  advantage  may  be  de- 
rived by  dividing  the  temporal  artery,  by  the  shoulder  of  a  lan- 
cet, or  by  a  scalpel.     No  difficulty  attends  this  operation;  nor  is 
any  thing  to  be  apprehended  from  an  artery  being  cut — a  slight 
compression  arrests  the  bleeding,  nor  is  there  the  least  risk  that 
the  bleeding  will  renew  itself. 

756.  The  head  of  the  patient  should  always  be  elevated;  and 
water  of  a  low  temperature,  in  a  large  bladder  should  be  applied 
to  it ;  but  this  must  be  under  restrictions  similar  to  those  laid 
down  for  its  use  in  fever.  (See  par.  533. )  The  hair  must  be  shaved 
off,  or  cut  very  close,  that  the  cold  may  be  quickly  perceived. 

757.  It  may  however  be  proper  to  observe,  that  the  propriety 
of  applying  ice  to  the  head  in  cerebral  inflammations  is  ques- 
tioned by  Mr.  Costa,  in  a  memoir  he  read  before  the  French 
"Academic  Royale  de  Medicine"  on  this  subject.     He  says, 
"  would  we  found  this  treatment,  (the  application  of  ice  to  the 
head,)  on  the  idea  that  the  inflammation  of  organs  contained 
within  the  brain  is  of  a  peculiar  nature?  But  MM.  Tomasin  and 
Broussais,  have  sufficiently  proved  that  inflammation  wherever 
situated,  and  whatsoever  its  causes,  is  always  the  same.     Now, 
then,  if  cerebral  inflammations  are  the  same  as  phlegmasise  of 
other  organs,  why  treat  them  differently  from  the  others  ?  can 
we  expect  to  oppose  the  flow  of  blood  by  the  intensity  of  the 
cold  ?» 

758.  The  author  is  of  opinion,  that  by  constringing  the  ves- 
sels of  the  scalp,  we  force  the  blood  they  contain  to  flow  back  on 
the  brain.     Under  this  impression,  he   proposes  in  idiopathic 
cerebral  inflammations  to  shave  the  head,  and  to  cover  it  with 
leeches  in  the  course  of  the  sagittal  suture,  and  especially  at  its 
posterior  extremity.     He  afterwards  covers  it  with  emollient 
poultices,  which  are  to  be  renewed  when  necessary ;  and  if  re- 
quired he  also  has  recourse  to  general  bleedings.     On  the  other 
hand,  if  the  inflammation  be  sympathetic  with  gastro-enteritis, 
which  is  frequently  the  case,  especially  in  children,  he  directs 
his  treatment  to  the  state  of  the  intestinal  tube ;  unless  the  affec- 
tion of  the  brain  greatly  predominates ;  in  which  case  he  pro- 
ceeds as  just  mentioned. 

759.  He  prefers  the  sinciput  for  the  application  of  leeches, 
because  the  inflammation  of  the  arachnoid,  or  encephalitis,  usually 
occupies  the  anterior  regions  of  the  head,  and  by  applying  leeches 
to  the  sinciput,  he  unloads  the  inflamed  parts  more  directly,  by 
acting  on  the  longitudinal  sinus,  or  rather  on  the  veins  which 
discharge  themselves  into  it ;  and  because  there  exists  a  sympa- 

30 


234  PHRENITIS. 

thy  between  the  skin  which  covers  the  splanchnic  cavities  and 
this  part. 

760.  In  aid  of  this,  the  stimulus  of  heat,  light,  and  noise,  must 
be  removed  as  far  as  is  practicable  and  proper  for  the  season,  and 
for  the  purposes  of  nursing.     All  conversation,  or  communica- 
tions, whether  of  an  agreeable  kind  or  otherwise,  must  carefully 
be  avoided — in  a  word,  all  the  directions  given  for  the  manage- 
ment of  fever  in  general,  must  be  here  put  in  practice. 

761.  Purging  in  idiopathic  phrenitis  is  of  much  consequence; 
this  should  be  performed  by  calomel,  in  doses  suited  to  the  age 
and  situation  of  the  patient;  rendered  active  by  an  after-dose  of 
the  sulphate  of  magnesia  or  Epsom  salts,  or  by  magnesia,  drink- 
ing lemonade  after  it.    A  free  discharge  must  be  maintained,  by 
castor  oil,  magnesia,  salts,  either  alone,  or  united.    In  the  symp- 
tomatic affection,  the  purging  must  be  regulated  by  the  nature 
of  the  original  affection.*     The  strictest  antiphlogistic  regimen 
must  be  insisted  on.  (See  par.  214,  215,  216.)    If  the  bowels  are 
tardy,  as  they  are  wont  to  be,  the  operation  of  the  medicines  just 
named  may  be  promoted  by  enemata  of  warm  salt  and  water. 

762.  Blisters  as  revulsives  are  highly  useful  when  the  system 
is  reduced  to  the  blistering  point.  (See  par.  260.)     They  should 
be  applied  to  the  calves  of  the  legs,  to  the  inside  of  the  thighs, 
or  to  the  forearms.     We  have  strong  doubts  of  the  propriety  of 
blistering  the  head — indeed,  we  are  of  opinion  that  it  is  inju- 
rious ;  to  the  shoulders,  is  less  objectionable,  though  not  a  de- 
cidedly eligible  spot. 

763.  Rubefacients  may  be  also  advantageously  employed,  after 
the  circulation  has  been  moderated,  and  especially  when  there  is 
a  tendency  to  congestion,  as  declares  itself  by  an  inequality  oi" 
heat  upon  the  surface,  and  especially  when  the  feet  and  legs  be- 
come cold.     Mustard,  Cayenne  pepper,  or  the  spirit  of  turpen- 
tine may  be  employed  for  this  purpose;  and  these  may  be  aided 
by  jugs  of  warm  water,  or  heated   bricks  placed  near  the  parts. 
Pediluvium  may  also  be  resorted  to,  provided  the  legs  of  the 
patient  can  be  made  to  hang  over  the  edge  of  the  bed,  without 
disturbing  him  too  much,  or  obliging  him  to  assume  a  horizontal 

•  We  would  direct  the  attention  of  the  practitioner  when  he  determines  on 
producing  catharsis,  that  it  is  only  in  the  idiopathic  form  of  phrenitis  that  this 
operation  can  be  valuable  or  sometimes  perhaps  even  safe.  For  while  he  may 
derive  prompt  and  decided  advantage  from  purging1  in  the  idiopathic,  he  may 
do  much  mischief  in  symptomatic  phrenitis;  especially,  when  the  original  seat 
of  disease  is  either  in  the  stomach  or  intestines;  or  if  he  give  in  these  cases, 
even  the  more  active  or  drastic  purgatives.  In  the  latter  form  of  phrenLtis  the 
milder  laxatives  should  be  employed;  as  castor  oil,  or  weak  solutions  of  the 
neutral  salts;  but  in  the  former,  from  the  direct  communication  of  the  vessels 
of  the  head  and  the  abdomen,  we  may  expect  much  advantage,  from  the  more 
active  cathartics. 


APOPLEXY.  235 

position.     His  drinks  should  be  the  same  as  those  directed  for 
fever  in  general.  (See  par.  214.) 

764.  When  phrenitis  succeeds  to  the  sudden  suppression  of 
any  accustomed  evacuation,  as  the  menses,  haemorrhoids,  &c. 
though  it  must  be  looked  upon  as  symptomatic,  it  will  neverthe- 
less require  almost  always,  active  treatment.     Bleeding,  leech- 
ing, purging,  &c.  as  already  directed  for  the  idiopathic  species; 
and  early  attempts  must  be  made  to  recall  the  habitual  dis- 
charge. 

765.  After  the  disease  has  disappeared,  the  utmost  caution 
should  be  exercised  in  returning  to  the  ordinary  mode  of  living — 
a  moderate  diet  should  be  persevered  in  for  some  time  after  all 
febrile  irritation  has  ceased,  lest  the  disease  be  recalled. 

SECT.  II. — APOPLEXY. 

766.  This  formidable  disease  early  attracted  the  attention  of 
medical  writers ;  hence,  we  find  it  mentioned  by  almost  every 
one  of  them  from  the  time  of  Hippocrates  to  the  present  day. 
And  in  no  other  disease,  perhaps,  have  descriptions  been  so  ac- 
curate, or  so  uniform.  But  notwithstanding  this  harmony  in  the 
history  of  the  symptoms  of  this  disease,  its  pathology  has  not 
been  ascertained  until  within  (comparatively)  a  very  short  time. 
Morgagni,  and  his  cotemporaries,  were  among  the  first  cultivators 
of  pathological  anatomy;  and  the  diseases  of  the  head,  from  their 
severity  and  frequency,  particularly  attracted  their  attention; 
especially  Morgagni.     In  his  great  work,  he  has  left  us  the  dis- 
sections of  a  considerable  number  of  apoplectics,  agreeing  in  de- 
tail pretty  much  with  those  of  later  observers,  but  without  being 
arranged  in  such  order  as  to  enable  us  to  draw  any  important 
practical  distinctions  from  the  varieties  of  appearance  he  disco- 
vered in  the  brain.     Extravasations  were  met  with  in  a  great 
majority  of  instances,  but  without  his  coming  to  a  conclusion 
that  there  was  any  coincidence  between  the  part  of  the  brain  oc- 
cupied by  them,  and  the  symptoms  that  had  preceded  death. 

767.  Indeed,  the  presence  of  a  foreign  body  within  the  cavity 
of  the  cranium,  was  held  sufficient  to  account  for  all  the  pheno- 
mena of  apoplexy;  and  here  inquiry  appeared  to  cease,  until 
within  a  very  short  period.    And  it  is  to  Serres  that  the  honour 
is  due,  of  having  first  suggested  and  traced  the  connexion  be- 
tween the  accompanying  symptoms  of  this  disease,  and  the  va- 
rious lesions  of  the  brain  and  its  appendages,  which  gave  rise  to 
them  ;  but  of  this,  more  by  and  by. 

768.  Several  definitions  have  been  given  of  apoplexy,  all  of 
which  agree  in  its  principal  phenomena,  yet  no  one  demonstrat- 
ing its  absolute  character,  as  will  be  seen  as  we  proceed.     Apo- 


236  APOPLEXY. 

plexy  is  said  by  Dr.  Good  to  consist  of  "  mental  and  corporeal 
torpitude,  with  oppressive,  mostly  stertorous  sleep."*  This  de- 
finition is  concise,  but  fails  perhaps  in  rigid  accuracy.  Dr.  Cooke's 
is  rather  more  comprehensive,  and  less  objectionable.  He  very 
modestly  says,  "  perhaps  apoplexy  may  be  thus  defined — it  is  a 
disease  in  which  the  animal  functions  are  suspended,  while  the 
vital  and  natural  functions  continue,  respiration  being  generally 
laborious,  and  frequently  attended  with  stertor."t 

769.  This  disease  sometimes  takes  place  so  suddenly,  as  to 
preclude  all  cognizable  premonition;  at  others,  there  may  be  a 
short  warning;  while  again,  it  may  advertise  us  of  its  approach 
by  a  number  of  well  marked  and  decided  symptoms.     These 
different  onsets  of  apoplexy  appear  to  be  governed  altogether  by 
the  condition  of  the  brain  itself,  or  of  its  meninges  at  the  moment 
of  attack,  or  a  short  time  previous  to  it. 

770.  When  warning  is  given,  the  following  circumstances  ge- 
nerally obtain.     A  sense  of  heaviness,  or  weight,  attended  by 
pain  in  the  head  of  less  or  greater  intensity;  vertigo,  or  only  a 
slight  dizziness;  disposition  to  sleep;  disturbed,  and  oppressed 
sleep,  or  nightmare;  involuntary  contractions  of  the  muscles  of 
the  face,  especially  during  sleep;  spasmodic  affections  in  various 
parts  of  the  body ;  redness,  and  fulness  of  the  face;  injected  eyes; 
inspiration  more  deep  than  natural;  indistinctness  of  vision;  ring- 
ing in  the  ears;  bleeding  from  the  nose;  faultering  of  the  speech, 
or  employing  inappropriate  words;  failure  of  memory,  and  dimi- 
nished sensibility  of  both  body  and  mind. 

771.  After  these  symptoms  have  continued  a  longer  or  shorter 
time,  or  sometimes  without  any  discoverable  previous  intimation, 
the  patient  falls  prostrate,  and  lies  as  if  in  a  profound  sleep,  but 
from  which -he  cannot  be  roused  by  any  excitation.  So  analogous 
in  appearance  is  apoplexy  to  profound  sleep,  that  at  first  sight  it 
might  be  difficult  to  distinguish  them,  and  which  led  Boerhaave 
to  declare  it  to  be  its  true  image. 

772.  Stertor  is  not  a  necessary  attendant  upon  apoplexy,  though 
it  is  of  frequent  occurrence;  nor  is  the  patient  entirely  deprived 
of  all  capacity  of  action,  if  it  be  admitted  that  he  is  of  all  sensa- 
tion— for  the  application  of  powerful  stimuli  will  produce  con- 
tractions of  the  muscles,  though  this  may  not  be  attended  by 
consciousness.     Dr.  Cooke  says,  "  in  tbe  strong  paroxysm,  per- 
sons are  said  to  be  entirely  deprived  of  sensation  and  motion; 
but  the  power  of  moving  is  occasionally  apparent,  and  we  cannot 
be  certain  that  the  power  of  feeling  in  these  cases  is  wholly  abo- 
lished.    I  have  seen  patients  in  this  disease  shrink  on  being 

*  Study  of  Medicine,  Am.  Ed.  Vol.  HI.  p.  394. 
•}-  Dr.  Cooke  on  Nervous  Diseases,  Vol.  I.  p.  166.  ' 


APOPLEXY.  237 

cupped,  and  move  their  hands  towards  the  head,  as  if  feeling 
uneasiness  there."  p.  168.  We  have  repeatedly  witnessed  the 
same  thing,  which  has  constantly  led  us  to  believe  that  all  sen- 
sation was  not  destroyed,  as  the  hand  directed  to  the  spot  on 
which  the  stimulus  was  applied,  cannot  be  regarded  as  a  mere 
automatic  motion. 

773.  Dr.  Wilson  Philip  thinks,  that  the  power  of  the  volun- 
tary muscles  remains;  as  he  declares  he  had  repeatedly  examined 
the  state  of  these  muscles  in  apoplexy,  both  in  warm  and  in  cold: 
blooded  animals,  and  found  their  excitability  unimpaired.     He 
therefore  is  of  opinion,  that  it  is  not  their  power,  but  the  stimu- 
lus which  excites  them,  that  is  lost  in  apoplexy. 

774.  Respiration,  for  the  most  part,  is  much  affected  in  this 
disease,  and  seems  to  be  laborious  in  proportion  to  the  extent  of 
the  proximate  cause.   It  is  not,  however,  suddenly  embarrassed, 
as  it  gradually  augments  as  the  disease  continues — thus,  it  is  fre- 
quently slow  and  regular  in  the  commencement,  though  it  may 
be  laborious ;  while  towards  its  close,  it  may  become  extremely 
slow,  or  very  frequent,  and  irregular.    It  is  said  that  the  danger 
is  in  proportion  to  the'derangement  of  this  faculty ;  and  that 
which  is  very  laborious  and  irregular  may  be  looked  upon  as 
one  of  the  most  unfavourable  symptoms.     It  is  observed  by  Dr. 
Cheyne,  that  "immediately  before  death,  the  respiration  is  irre- 
gular, and  is  performed  not  oftener  perhaps  than  three  or  four 
times  in  a  minute." 

775.  This  slow  and  laborious  breathing  in  generally  accom- 
panied by  stertor.     And  when  the  disease  is  attended  by  this 
symptom,  both  Boerhaave  and  Portal,  consider  it  in  its  most 
aggravated  form.     There  is  also  a  quantity  of  saliva  blown  from 
the  mouth  in  the  form  of  foam,  which  also  marks  the  intensity 
of  the  disease. 

776.  The  pulse  is  constantly  affected  ;  in  the  beginning  it  is 
for  the  most  part  slow,  regular,  full,  and  hard ;  but  in  a  few- 
hours,  M.  Serres  informs  us,  both  it  and  the  respiration  become 
much  affected.     He  says,  "  in  a  few  hours  after  the  invasion,  (if 
the  brain  have  not  already  suffered  laceration  on  some  point  of 
its  various  surfaces,)  the  respiration  becomes  considerably  slower 
than  natural.     The  venous  blood  thus  experiences  a  mechanical 
obstruction  to  its  return  to  the  heart,  and  the  latter  organ  begins 
to  react  in  proportion;  the  pulse  accordingly  becomes  hard,  and 
frequent;  the  artery  vibrates  as  it  were  under  the  finger;  in  short, 
the  action  of  the  heart  is  quickened  in  proportion  as  the  respi- 
ratory process  is  retarded."     And  agreeably  to  Dr.  Cheyne,  the 
irritability  of  the  heart  survives  the  respiration.    "  Sitting,  with 
my  finger  over  the  artery  of  a  person  who  died  of  apoplexy,  I 
distinctly  felt  the  pulse  beat  after  the  last  expiration."  (p.  14.) 


238  APOPLEXY. 

The  pulse  in  the  beginning  of  the  attack,  rarely  exceeds  fifty 
strokes  in  a  minute. 

777.  Indeed,  in  one  case,  and  that  slight,  as  the  patient  re- 
covered his  senses  in  a  short  time,  the  pulse  was  not  more  than 
thirty-four  strokes  in  the  minute ;  full,  tense,  and  equal.   We  can- 
not say  what  was  the  state  of  the  respiration,  as  we  did  not  see 
him  until  he  was  able  to  give  an  account  of  himself.  The  attack 
was  sudden  and  without  warning,  according  to  his  own  state- 
ment— he  was  suddenly  seized  while  walking  in  the  garden  at  his 
country  seat,  and  fell  upon  the  ground.    How  long  he  remained 
in  this  situation  he  cannot  tell;  but  it  was  a  considerable  time  he 
thinks,  by  the  apparent  waste  of  the  day.     No  one  saw  him  in 
this  situation  ;  after  this  his  head  remained  giddy  and  rather  pain- 
ful, especially  on  the  left  side.*  We  saw  him  for  the  first  time, 
the  day  after  these  events  had  taken  place;  he  was  much  weak- 
ened; head  always  slightly  painful,  and  occasionally,  considera- 
bly so  ;  his  breathing  pretty  free,  though  the  expiration  was  per- 
formed rather  suddenly,  especially  after  talking  a  little.     The 
pulse  was  at  thirty-four  at  most,  occasionally  as  low  as  twenty- 
eight,  indeed,  a  number  of  times  not  more  than  twenty-six  strokes 
in  a  minute;t  there  was  nothing  like  paralysis  in  any  portion  of 
the  body.     Depletion  was  as  frequently  employed  during  the 
period  of  three  months,  and  in  as  liberal  a  manner,  as  was  con- 
sistent with  the  safety  of  one,  who  had  exceeded  seventy-three 
years,  and  who  was  naturally  of  a  feeble  constitution. 

778.  He  gradually  recovered  nearly  his  usual  state  of  health; 
and  remained  so  until  a  few  days  over  a  year  from  the  attack 
just  spoken  of.     At  this  period  he  began  to  experience  a  heavi- 
ness and  occasional  pain  in  the  head ;  his  pulse  keeping  about 
thirty-two,  tense,  and  full — he  lost  a  few  ounces  of  blood,  was 
purged  and  kept  upon  a  very  abstemious  diet  for  some  time,  by 
which  means  these  symptoms  disappeared.   He  remained  in  this 
situation  for  two  months,  when  pretty  soon  after  dinner,  he  fell 
suddenly  from  his  chair  upon  the  floor.  We  were  instantly  sent 

*  This  gentleman  had  for  three  or  four  weeks,  five  or  six  times  a  day,  what 
he  called  "shocks,"  through  the  brain,  especially  upon  the  whole  half  of  the 
left  side.  These  "  shocks"  would  be  both  painful  and  astounding  for  some 
minutes  together. 

•j-  This  patient  was  a  remarkably  close  observer — he  very  frequently  exa- 
mined his  pulse  by  an  accurate  stop-watch  with  a  quarter  second  movement — 
he  recorded  all  the  sensations  he  experienced,  and  marked  each  varying 
change — he  was  learned,  and  very  studious,  and  consequently  very  seden- 
tary— a  very  moderate  feeder,  and  never  drank  any  thing  stronger  than  a  weak 
mixture  of  claret  and  water,  and  not  much  even  of  that,  and  this  only  at  his 
dinner.  His  bowels  always,  very  regular  in  their  motions;  indulged  but  little 
in  bed,  and  habitually  an  early  riser — not  given  to  any  sudden  gusts  of  passion, 
and  of  a  cheerful  disposition.  He  had  been  subject  many  years  however,  to  a 
catarrh  of  the  bladder,  and  slight  irregularities  in  his  urinary  discharges. 


APOPLEXY.  239 

for;  but  living  at  a  considerable  distance  from  him,  three-quarters 
of  an  hour  had  elapsed  before  we  saw  him.  He  was  still  lying 
on  the  floor,  with  his  head  elevated;  but  pale;  his  mouth  drawn 
to  one  side;  he  was  senseless.  It  was  stated,  that  he  was  slightly 
convulsed ;  frothed  at  the  mouth,  and  snored ;  his  faeces  and 
urine  were  discharged  during  the  paroxysm. 

779.  His  pulse  was  twenty-six  strokes  in  the  minute,  and 
scarcely  perceptible;  his  breathing  not  much  affected;  the  skin 
bedewed  with  a  cold  clammy  sweat;  but  little  more  of  the  eyes 
could  be  seen  than  the  whites;  strabismus;  and  a  considerable 
quantity  of  a  tenacious  saliva  running  from  the  mouth. 

780.  We  caused  his  legs  to  be  rubbed  with  hot  brandy  and 
mustard  ;  spirit  of  turpentine  was  applied  to  the  region  of  the 
stomach,  and  a  number  of  hot  bricks  were  placed  at  different 
parts  of  the  body.     Reaction  soon  after  took  place;  the  skin  be- 
came warmer;  the  pulse  more  expanded,  but  not  more  frequent; 
the  countenance  more  composed  and  less  ghastly ;  the  mouth 
however  remained  contracted ;   though  the  squinting  was  re- 
moved.    He  became  gradually  sensible  of  things  around  him, 
though  he  could  not  articulate  when  he  attempted  to  answer  any 
question.     He  now  lost  eight  ounces  of  blood  from  the  arm, 
with  marked  ad  vantage,  as  his  speech  returned  while  the  bleeding 
was  performing.   He  gradually  mended,  and  went  to  the  country, 
and  while  there,  was  again  assailed  by  similar  apoplectic  symp- 
toms; these  were  not  of  long  continuance,  or  of  great  severity, 
but  they  were  followed  by  a  paralysis  of  the  right  side.     He  was 
cupped,  and  purged ;  and  in  a  few  days  after,  was  put  upon  the 
use  of  the  white  mustard-seed,   under  the  use  of  which,   he 
gradually  acquired  the  use  of  his  arm  and  leg.   His-pulse,  during 
the  whole  progress  of  this  affection,  never  exceeded  thirty-four 
strokes  in  a  minute,  but  has  been  occasionally,  as  low  as  twenty- 
six. 

781.  This  case  is  remarkable  in  several  of  its  particulars; 
first,  the  mildness  of  the  original  attack — the  second,  being  at- 
tended, with  several  threatening  symptoms,  such  as  the  partial 
paralysis  of  the  face;  the  distortion  of  the  eyes,  and  the  loss  of 
speech,  all  of  which   disappearing,  and  the  patient  regaining, 
nearly  his  ordinary  health — the  third,  being  followed  by  a  para- 
lysis of  one  side,  without  the  loss  of  speech   or  drawing  of  the 
mouth,  but  above  all,  the  long-continued  (nearly  two  years,)  and 
uniform  slowness,  of  the  pulse.* 

782.  The  temperature  of  the  skin  is  sometimes  higher  than 
natural  ;  at  other  times,  it  is  cold  and  sweaty — the  latter  some- 
times, profuse,  in  other  instances,  a  well-marked  febrile  condi- 

*  This  patient  a  few  months  after  died  while  sitting  in  his  chair,  almost  in 
an  instant. 


240  APOPLEXT. 

tion  of  the  system  may  be  observed.  Dr.  Cooke  says  tbat  "  fe- 
ver however  is  not  generally  mentioned  in  the  history  of  apo- 
plexy and  I  believe  seldom  accompanies  it."  (p.  173.)  We  do 
not  ourselves  think,  that  fever  necessarily  belongs  to  the  history 
of  this  disease,  but  nevertheless  we  have  seen  it  well  marked  in 
several  instances. 

783.  The  eyes  in  this  disease,  are  generally  injected,  and 
rather  prominent,  sometimes  they  are  only  half  closed,  at  other 
times  completely  shut.     The  pupil  for  the  most  part  is  dilated, 
and  others  greatly  and  permanently  contracted.   Dr.  Cooke  says, 
"  in  some  instances  I  have  seen  the  pupils  contracted  to  a  point, 
and  a  physician  of  eminence  of  my  acquaintance  has  likewise  ob- 
served this  appearance  of  the  eyes  in  apoplexy;  yet  although  all 
writers  on  the  subject  mention  the  dilation  of  the  pupils,  I  do 
not  find  any  one,  (Aretseus  among  the  ancients,  and  Dr.  Cheyne 
among  the  moderns,  excepted,)  who  has  noticed  the  contracted 
pupils  in  these  cases."  p.  174. 

784.  The  teeth  are  frequently  clenched  very  firmly  together ; 
so  much  so  sometimes  as  to  render  it  extremely  difficult,  to  get 
any  liquid  into  the  mouth;  nor  is  it  unusual  in  an  attempt  of  this 
kind,  to  find  it  returned  by  the  nostrils. 

785.  As  this  disease  approaches  to  a  fatal  termination,  the 
symptoms  become  more  and  more  intense — the  abolition  of  sense 
and  motion  becomes  complete;  the  pulse  becomes  weak,  very 
frequent,  and  indistinct,  and  these  symptoms  are  sometimes  fol- 
lowed by  convulsions,  which  close  the  scene;  at  other  times, 
the  extinction  of  life  is  so  gradual,  and  so  tranquil  as  scarcely  to 
be  observed  when  it  takes  place.     The  duration  of  this  disease, 
•will  be  very  much  influenced  by  the  force  and  number  of  the 
remote  causes;  and  the  extent  and  location  of  the  lesion  they  may 
produce — thus,  it  may  happen  in  a  few  minutes  or  within  an 
hour,  or  it  may  persist  for  days.     We  agree  with  a  number, 
who  believe  that  many  of  those  sudden  deaths  attributed  to  this 
disease,  depend  upon  some  disease  of  the  heart,  or  of  the  large 
blood-vessels. 

Predisposing  Causes. 

786.  Various  causes  have  been  assigned  as  predisposing  to  this 
disease;  as  hereditary  transmission  by  conformation;  this  by 
some  has  been  considered  as  well  grounded  ;  Forestus  in  con- 
firmation   of   this    opinion,   mentions  a  father  and  three    sons 
dying  of  apoplexy  ;*  old  age  is  also  said  to  be  predisponent  to 
this  disease ;  Rochoux  is  of  this  opinion.     The  translation  of 
gout;  the  suppression  of  accustomed  evacuations;  and  the  re- 

*  Dr.  Cooke  on  Nervous  Diseases,  Vol.  I.  p.  199. 


APOPLEXY.  241 

polling  of  certain  eruptive  affections,  have  always  been  consider- 
ed, and  with  great  propriety,  as  belonging  to  these  causes. 

787.  But  this  must  certainly  be  contingent,  since  we  find  no 
age  exempt  from  it.  Serres  says,  "it  is  an  established  fact  that 
apoplexies  may  attack  all  ages — I  have  observed  them  in  all 
the  periods  of  life,  from  the  age  of  three  years,  up  to  decrepid 
old  age."*  And  Rochoux  gives  a  statement  of  sixty-three  cases, 
in  the  following  order: — 

Age.  Number  of  cases. 

From  20  to  30  years  2 

30  to  40  8 

40  to  50  7 

50  to  60  -       10 

60  to  70  -       23 

70  to  80  -       12 
80  to  90               -         -         -         -         -          1 


Total,     63t 


788.  This  table  goes  far  to  prove  the  accuracy  of  Hippocrates' 
statement,  that  apoplexies  chiefly  take  place  between  the  fortieth 
and  sixtieth  years;  though  not  altogether  confirmed  by  the  ob- 
servations of  Serres.     Rochoux  remarks  upon  these  cases,  "that 
there  are  more  people  living  of  the  age  of  sixty  than  of  seventy ; 
but  that  he  can  hardly  believe  that  the  number  is  double,  yet  it 
is  seen,  that  the  age  of  sixty  has  furnished  almost  double  the 
number  of  apoplectic  subjects.     Besides,  if  it  be  admitted,  that 
there  are  more  of  the  age  of  sixty  than  the  age  of  seventy,  there 
are  also  more  of  fifty,  than  of  sixty,  yet  the  latter  age  gives  more 
than  double  the  number  of  patients.  By  this  it  may  be  perceived, 
that  the  predisposition  to  apoplexy  increases  towards  sixty,  and 
diminishes  towards  seventy.     That  this  disposition  is  but  little, 
before  thirty,  and  that  the  number  is  extremely  small  before 
twenty ;  and  the  influence  of  temperament,  is  very  far  from  fur- 
nishing the  same  results;  the  sanguine,  sanguino- bilious,  and  the 
sanguino-lymphatic,  furnish  nearly  an  equal  number  of  cases  of 
this  disease. "J 

789.  Serres  has  declared  that  apoplexy  may  take  place  at  any 
period  of  life;  if  this  be  so,  dentition  in  children  must  be  looked 
upon  as  a  predisposing  cause,  with  them.     The  sudden  altera- 
tions in  atmospheric  temperature,  as  well  as  moisture,  have  ever 

*  Philadelphia  Journal  of  the  Medical  and  Physical  Sciences,   Vol.  VIII, 
p.  294. 

•j-  Hecherches  sur  Apoplexie,  p.  212.  t  Ib.  p.  213. 

31 


242  APOPLEXY. 

been  looked  upon  as  predisponents.  Large  heads  and  short 
necks;  and,  agreeably  to  Ponsart,*  a  small  head  equally  disposes 
to  apoplexy.  Obesity,  gluttony,  drunkenness,  &c.  Tempera- 
ment, agreeably  to  Rochoux,  seems  to  have  no  very  marked  in- 
fluence. 

Exciting  Causes. 

790.  Among  the  exciting  causes,  an  overcharged  stomach, 
is  considered  by  many  as  the  most  common;  excessive  venery, 
especially  in  aged  people;  passions  and  emotions  of  the  mind; 
labour  in  females,  especially  with  the  first  child;  sudden  appli- 
cation of  cold,  &c.     The  mode  of  action  of  these  causes,  is,  by 
increasing  the  force  and  rapidity  of  the  circulation,  as  well  as  an 
especial  determination  to  the  head ;  yet  it  is  evident,  that  there 
must  be  causes  which  constantly  produce  these  effects,  even  in  a 
more  violent  degree,  yet  they  do  not  produce  apoplexy.  Rochoux 
directs  our  attention  to  "tumblers  and  mountebanks,  who  stand 
long  upon  their  heads;  who  will  place  an  anvil  upon  their  belly, 
which  they  allow  to  be  forcibly  struck  with  a  hammer,  &c.     If 
then  apoplexy  have  taken  place  from  apparently  slight  causes,  we 
must  attribute  it  to  some  alteration  in  the  vessels  of  the  head ; 
their  having  become  too  weak  to  prevent  the  escape  of  the  blood 
with  which  they  are  filled.  Of  this  it  might  be  easy  to  convince 
ourselves,  by  taking  at  random,  a  twentieth  part  of  the  histories 
of  apoplexy  ;  the  three-fourths  of  which  would  be  found  to  have 
had  a  paroxysm,  without  being  able  to  suspect  the  cause.  And  is 
it  not  probable,  that  the  other  fourth,  may  assign  causes  for  this 
disease,  which  were  altogether  fortuitous,  and  have  had  but  a 
trifling  agency  in  the  production  of  it?"  p.  218.     The  too  fre- 
quent and  long-continued  use  of  the  warm  bath.     We  once  wit- 
nessed this  affection  in  a  young  lady,  after  having  her  feet  and 
legs  placed  in  very  warm  water;  she  fell  suddenly  from  her 
chair,  with  all  the  usual  marks  of  apoplexy  attending — she  was 
largely  bled;  and  other  means  were  liberally  employed,  before 
she  recovered — she  suffered  with  head-ache  many  months  after 
this  attack,  t 

Pathology  of  Apoplexy. 

791.  "  A  man  falls  down  with  all  the  symptoms  of  apoplexy, 

•  Traite  de  1'Apoplexie  et  de  la  Paralysie,  p.  14,  as  quoted  by  Rochoux. 

f  Fourcroy  relates  the  case  of  a  person,  who  immersed  himself  in  a  bath  of 
66°  of  Reaumer,  equal  to  180°  of  Fahrenheit,  and  who  fell  down  an  hour  after- 
wards apoplectic.  And  Buchan  gives  an  account  of  another  who  was  seized 
with  paralysis  after  having  subjeeted  himself  to  a  very  warm  bath. 


APOPLEXY.  243 

but  by  bleeding,  purging,  and  other  means,  he  perfectly  recovers. 
Another  dies  under  apparently  similar  circumstances  and  treat- 
ment, and,  on  dissection,  extravasation  of  blood  is  found  within 
the  head.  A  third  dies  of  apoplexy,  and  only  serum  is  effused. 
A  fourth  presents  after  death  only  a  turgescency  of  the  vascular 
system  of  the  brain;  while  a  fifth,  who  dies  with  every  symptom 
of  perfect  apoplexy,  presents  on  dissection,  no  cognizable  trace 
of  lesion  in  the  brain,  or  any  other  org?n  of  the  body.  These 
various  and  contradictory  appearances,  post  mortem,  would  seem 
to  offer  an  insuperable  objection  to  any  fixed  pathology  of  apo- 
plexy; or  at  least,  might  apparently  sanction  a  division  of  the 
disease  into  different  species.  Nevertheless,  we  will  endeavour 
to  maintain  an  identity  of  morbid  state,  or  in  other  words,  of 
pathology  in  apoplexy,  whatever  may  be  the  appearances  after 
death.  We  consider  pressure*  on  the  cerebral  mass,  or  its  ap- 
pendages, as  the  real  efficient  cause  of  the  apoplectic  phenomena 
in  every  case."t 

Proximate  Cause. 

792.  This  opinion  of  the  proximate  cause  of  apoplexy  has  been 
almost  universally  adopted  within  the  last  few  years;  and  the 
result  of  very  many  post  mortem  examinations  would  seem  to 
confirm  it.  Its  truth  has,  however,  been  lately  called  in  question 
by  M.  Serres.    He  endeavours  to  prove  that  pressure  is  not  the 
cause  of  apoplexy,  and  commences  by  asking,  "are  effusions  the 
cause  or  the  effect  of  apoplexies?"    He  determines  this  question 
in  the  negative,  from  the  result  of  the  following  experiments.  J 
They  are  first  conducted  on  animals,  and  secondly  upon  the 
human  subject. 

793.  Experiment  L — An  old  dog  was  trepanned  immediately 
over  the  superior  longitudinal  sinus — the  sinus  was  opened  by  a 
bistoury  its  whole  length,  and  the  external  wound  was  closed,  that 
a  sanguineous  effusion  might  take  place.     In  three  hours  its  na- 
tural state  was  so  little  changed,  it  was  doubted  that  effusion  had 
taken  place. 

794.  "  On  opening  the  cranium,  we  found  a  very  considerable 
clot  of  blood  between  the  lobes,  and  a  second  extended  to  the 
left  hemisphere." 

795.  This  experiment  was  repeated  upon  a  young  dog,  lest  it 

*  We  have  taken  for  granted,  that  the  word  pressure,  as  employed  in  this 
quotation,  referred  to  this  mechanical  act,  from  extravasations  within  the  cra- 
nium— in  this  we  may  be  wrong;  and  if  so,  we  beg  its  author's  pardon,  for 
having  mistaken  his  meaning. 

f  Medico- Chirurg.  Review,  p.  7.  Vol.  I.  for  1820. 

*  We  have  even  abridged  the  short  histories  of  M.  Serres'  experiments,  by 
only  retaining  such  parts  as  bear  upon  the  points  at  issue. 


244  APOPLEXY. 

might  be  thought  that  in  the  old  dog  the  sinking  down  of  the 
brain  might  leave  a  void  between  it  and  the  cranium.  The  result 
was  the  same.  In  neither  instance  was  there  the  slightest  appear- 
ance of  apoplexy.  Rabbits  and  birds  were  subjected  to  similar 
trials  with  like  results — "  no  somnolency,  none  of  the  symptoms 
which  accompany  apoplexies." 

796.  "  There  was  already  strong  presumption  against  the  ge- 
nerally received  opinion;  for  I  could  compare  this  effusion  to 
those  which  occur  in  the  course  of  apoplexies  between  the  dura 
mater  and  the  arachnoid  coat,  or  between  this  and  the  pia  mater — 
apoplexies  in  which  the  substance  of  the  brain  is  not  involved." 

797.  "  Artificial  Effusions  in  the  Ventricles." — To  deter- 
mine the  effects  of  this,  a  number  of  experiments  were  inge- 
niously made,   by  penetrating  them  with  a  sharp  instrument. 
The  corpus  callosum  of  a  grown  dog  was  pierced,  and  the  point 
of  the  instrument  made  to  enter  the  left  ventricle.     The  instru- 
ment was  withdrawn,  and  the  wound  closed. 

798.  "  The  animal  had  a  vertigo  of  a  minute's  duration — it 
was  uncomfortable  the  whole  day — had  a  little  agitation  in  the 
pulse,  and  violent  thirst,  but  there  was  no  somnolency;  his  sleep 
in  the  night  was  troubled.   In  the  morning,  he  walked  about  the 
laboratory.   In  three  hours  the  cranium  was  opened;  the  effused 
blood  had  filled  the  great  fissure  between  the  lobes,  and  pene- 
trated the  left  ventricle,  which  contained  an  ounce  and  an  half 
of  it — a  small  cavity  was  found  in  the  anterior  part  of  the  corpus 
callosum,  (middle  lobe.")     This  experiment  was  repeated  upon 
a  rabbit  with  a  similar  result. 

799.  ^  Artificial  Excavations  formed  in  the  Cerebral  Sub- 
stance"— An  old  dog  was  chosen  for  the  experiment.     Two 
drachms  of  the  left  hemisphere  of  the  brain  was  removed  by  a 
bistoury ;  no  sleepiness  or  impeded  respiration  followed  its  re- 
moval.    An  excavation  containing  a  coagulum  of  the  size  of  a 
nut  was  situated  in  the  middle  of  tkis  lobe.    On  another  animal, 
a  cavity  was  made  in  each  lobe  of  the  brain  with  like  result — no 
apoplectic  symptoms.     The  same  was  performed  on  a  pigeon — 
no  somnolency. 

800.  Experiment  Sixth. — "  I  made  an  artificial  opening  into 
the  middle  part  of  one  of  the  hemispheres;  I  took  away  a  certain 
quantity  of  the  cerebral  substance — I  thrusted  a  cork  into  the 
aperture  in  the  manner  of  a  plug,  so  as  to  augment  the  pressure. 
There  was  a  complete  hemiplegia,  but  no  apoplexy,  no  somno- 
lency."    These  experiments  were  repeated  upon  rabbits,  birds, 
oxen,  and  horses,  with  like  results.     From  these  the  following 
important  deductions  are  made. 

801.  "Thus  sanguineous  effusions  do  not  produce  apoplexies, 
whether  they  be  lodged  between  the  cranium  and  the  dura  mater, 


APOPLEXY.  245 

or  between  this  membrane  and  the  brain — whether  they  occupy 
the  grand  interlobulary  fissure,  and  in  this  manner  rest  upon  the 
corpus  callosum — whether  we  have  formed  a  cavity  in  the  he- 
mispheres, before,  behind,  or  in  the  middle,  or  pierced  it  from 
one  side  to  the  other — whether  in  fine,  in  traversing  the  corpus 
callosum,  (middle  lobe,)  we  had  penetrated  into  the  ventricles, 
and  filled  these  cavities.  The  same  result  with  rabbits,  the  same 
with  birds,  the  same  result  upon  dogs.  The  apoplexy  of  man, 
therefore,  cannot  be  attributed  to  the  presence  of  the  effused 
blood,  whatever  place  it  may  occupy  ;  whether  it  be  found  out  of 
the  brain,  or  in  the  cavities  of  that  organ,  or  lodged  in  its  proper 
substance." 

802.  "Experiments  relative  to  man." — "Do  the  facts  of 
pathological  anatomy  relative  to  the  brain  of  apoplectic  persons 
contradict  my  experiments?"     He  refers  for  the  answer  to  this 
question  "to  the  annals  of  our  science."     He  cites  a  case  from 
Vesalius,  of  a  child  of  two  years  old,  having  nearly  nine  pounds 
of  "  serosity"  in  the  circumvolutions,  and  ventricles  of  the  brain, 
yet  there  was  neither  "somnolency,  convulsions,  or  paralysis." 
Another  from  Wepfer,  of  a  man  of  seventy,  who  died  of  con- 
sumption, and  who  "had  spoken  to  the  moment  of  his  death," 
in  whose  "ventricles  and  between  the  meninges  a  great  quan- 
tity of  limpid  serosity"  was  found.    Another  witnessed  by  him- 
self, in  which  there  was  delirium  to  the  moment  of  death;  the 
brain  was  a  little  softened,  and  "  an  enormous  quantity  of  sero- 
sity occupying  its  infractuosities,  the  four  ventricles,  and  the 
canal  of  the  spine."     In  an  old  man  of  seventy,  who  died  of 
dropsy,  and  who  preserved  his  senses  to  the  last  moment,  was 
found  a  sanguineous  serosity  in  the  left  ventricle  of  the  brain, 
and  clotted  blood  in  the  right. 

803.  His  seventh  "  observation,"  relates  to  a  person  who  had 
been  three  weeks  recovered  from  an  apoplexy,  but  who  died  of 
a  pleurisy  on  the  seventeenth  day  of  his  new  disease.     "On 
opening  the  cranium,  a  clot  of  blood  of  the  size  of  a  small  egg, 
was  found  lodged  in  the  cortical  substance  of  the  great  left  lobe." 
The  eighth,  was  a  patient  who  sunk  "into  an  adynamic  state 
the  eighth  day  after  his  entry  into  the  hospital."     "  The  apo- 
plectic attack  which  had  produced  hemiplegia,  had  taken  place 
six  weeks  before  his  death :  since  that  time  no  symptom  of  apo- 
plexy.   On  opening  the  head,  a  sanguineous  effusion  was  found 
in  the  middle  of  the  great  lobe."  The  ninth,  was  a  woman  who 
died  of  puerperal  fever.     "  A  hard  coagulum  was  lodged  in  the 
cortical  substance  of  the  right  lobe — this  woman  had  a  "coup  de 
sang,"  two  years  before.     His  tenth,  eleventh,  and  twelfth,  are 
in  the  main  of  a  similar  character  and  go  to  prove  the  same  posi- 


246  APOPLEXY. 

tion,  that  extravasated  fluids  may  remain  harmlessly  in  the  brain 
after  the  symptoms  of  apoplexy  have  been  removed,  and  conse- 
quently, that "  neither  effusions  into  the  ventricles,  or  on, or  in  the 
substance  of  the  brain,  nor  excavations  of  its  medulla,  are  the 
causes  of  apoplexy." 

804.  Mr.  Serres  informs  us,  that  the  above  observations  were 
selected  from  twenty-two  analogous  cases,  which  he  had  collect- 
ed in  the  hospital  of  "La  Pitie."  From  these  facts  he  decidedly 
infers,  "  if  compression  by  fluids  be  the  cause  of  apoplexy,  a 
direct  consequence  is,  that — no  apoplexy  can  exist  without 
effusion.   Now  I  am  only  embarrassed"  he  says,  "in  the  choice 
of  authorities  and  facts  to  prove  the  contrary."    And  eventually 
declares  from  these  premises,  that  there  are  apoplexies  without 
effusions;  and  effusions  without  apoplexies;  and  that  he  is  "led 
to  a  belief  that  the  effusions  are  the  effects,  and  not  the  cause  of 
apoplexies." 

805.  He  next  attempts  to  ascertain,  whether  apoplexies  offer 
any  appreciable  differences  during  their  development  and  con- 
tinuance; and  whether  these  have  a  constant  relation  to  the  seat 
of  the  disease,  and  whether  this  is  supported  by  dissection  ;  and 
lastly,  whether  the  seat  of  apoplexies  can  be  determined  by  the 
presence  or  absence  of  these  certain  symptoms,  and  thus  establish 
a  mode  of  treatment.    During  his  endeavours  to  distinguish  san- 
guineous, from  serous  apoplexies,  he  discovered,  that  this  disease 
presented  two  different  forms — one  simple,  and  the  other  always 
complicated  \vith  paralysis. 

806.  He  now  asks,  "was  this  remarkable  circumstance  the 
effect  of  accident,  or  did  it  depend  upon  discoverable  causes  ?" 
The  answer  he  says  "was  given  to  me  by  the  histories  of  an 
hundred  apoplexies." 

807.  "Of  this  number,  twenty-one  were  simple ;  seventy-nine 
were  complicated  with  paralysis.     Of  the  first,  dissection  gave 
the  following  results — sixteen  had  collections  of  serum  either  in 
the  ventricles  and  cerebral  convolutions,  or  in  the  ventricles,  or 
in  the  convolutions  separately ;  one  had  a  sero-sanguineous  col- 
lection in  the  left  ventricle ;  two  had  similar  collections  between 
the  arachnoides  and  pia  mater  in  both  hemispheres;  and  two  were 
without  any  collection."  In  all  these  cases  the  brain  was  sound; 
but  the  membranes  were  affected  in  various  degrees;  the  vessels 
were  injected,  thickened,  opaque,  and  sprinkled  with  miliary 
granulations. 

808.  From  the  constant  correspondence  between  the  altera- 
tions of  the  membranes,  and  the  effusion,  he  was  led  to  suppose 
there  was  some  connexion  between  them ;  he  was  therefore  led 
to  the  conclusion,  that  in  the  meningeal  apoplexy,  the  mem- 


APOPLEXY.  247 

branes  are  primarily  and  principally  affected,  and  that  the 
various  effusions  which  are  met  with  are  nothing  but  the  effects 
of  these  alterations. 

809.  Whereas,  in  apoplexies  complicated  with  paralysis,  there 
were  no  effusions,  either  serous  or  sanguineous  in  the  natural 
cavities  of  the  brain,  nor  in  the  space  between  duplicatures;  no 
alteration  in  the  texture  of  the  membranes — but  the  brain  was 
materially  altered  in  structure — excavations  were  dug  in  its  sub- 
stance ;  the  whole  surrounding  texture  bore  marks  of  irritation. 
The  blood  which  was  extravasated,  was  found  to  proceed  from  a 
rupture  of  a  vessel,  which  was  proved  by  filling  the  carotids  with 
fine  injection,  and  observing  that  it  penetrated  the  cavities. 

810.  He  now  inquires  why  all  the  cerebral  apoplexies,  (that 
is,  apoplexies  attended  by  lesions  of  the  brain,)  should  be  ac- 
companied by  paralysis,  while  the  meningeal,  should  not  be  at- 
tended by  a  loss  of  motion.   He  answers  these  questions  by  say- 
ing that  apoplexies  followed  by  paralysis,  is  the  necessary  effect 
of  an  organic  alteration  of  the  proper  substance  of  the  brain, 
while  in  meningeal,  or  simple  apoplexies,  the  brain  being  sound 
the  capacity  for  motion  would  remain'unimpaired. 

811.  From  these  important,  and  interesting  facts,  he  arrives 
at  the  following  novel  deductions: — 1st.  That,  when  apoplexy 
is  not  complicated  by  paralysis,  the  disease  is  seated  in  the  mem- 
branes of  the  brain.   2d.  That  when  attended  by  palsy,  the  brain 
is  the  seat  of  the  irritation.  3d.  That  serous,  or  sero-sanguineous, 
bloody,  or  purulent  collections,  are  effects  of  irritation  of  the 
membranes,  or  the  brain,  or  of  arterial,  or  venous  rupture. 

812.  He  thinks,  from  these  considerations,  apoplexies  should 
be  designated  as  follows  : — 1st.   Meningeal  apoplexy — is  apo- 
plexy without  palsy.     2d.    Cerebral  apoplexy — apoplexy  with 
palsy.     Thus  he  thinks  we  are  enabled  to  determine  the  nature 
of  the  disease  we  have  to  contend  with  during  the  life  of  the  pa- 
tient.    If  it  be  simple,  the  patient  can  move  his  limbs;  the  dis- 
ease is  then  in  the  membranes.     If  he  cannot  move  his  limbs, 
and  the  mouth  distorted,  it  is  a  cerebral  apoplexy,  that  we  have 
to  encounter. 

813.  "The  meningeal  apoplexy  principally  attacks  youths  from 
the  age  of  fifteen,  and  old  men  past  sixty — it  generally  affects 
females  before  the  last  named  period."     "Of  forty  meningeal 
apoplexies,  there   were   thirty-two  in   females,  and    eight    in 
males. 

814.  Attack. — "Physicians  have  differed  greatly  in  the  mode 
of  attack  in  apoplexies.  One  party  has  said  that  they  always  come 
on  suddenly — the  other,  that  the  attack  is  preceded  by  precur- 
sory symptoms,  which  manifest  themselves  many  days  previous. 


248  APOPLEXY. 

Both  sides  have  been  right,  and  both  in  a  certain  degree  wrong, 
as  the  cases  may  have  been  meningeal  or  cerebral." 

815.  The  meningeal  apoplexy  is  almost  always  slow;  has  pre- 
cursory symptoms,  as  torpor ;  difficulty  in  exercising  the  mind, 
and  its  becoming  easily  fatigued  ;  perception   blunted;  drowsi- 
ness ;  respiration  slower  than  ordinary — tardy  circulation  ;  less 
warmth  than  usual ;  secretions  diminished ;  impaired  digestion, 
and  sometimes  vomiting. 

816.  Mr.   Serres  asks,   "what  distinguishes  apoplexy  from 
sleep  ?"     He  answers  the  question  by  the  following  important 
observations.     "  In  sleep  the  respiration  is  slow,  and  the  circu- 
lation is  in  a  relative  proportion — in  apoplexy  the  natural  rela- 
tion is  destroyed." 

817.  Whatever  difference  age  and  strength  may  make,  in  the 
number  of  pulses  in  a  given  time,  the  discordance  between  them 
and  respiration  never  fails  to  show  itself;  and  when  this  is  at  its 
maximum,  the  stupor  is  also.     Thus  Mr.  S.  relates  a  case  in 
which  the  following  extreme  of  disparity  between  the  pulse  and 
respiration  existed — pulse,  eighty-three  strokes  to  eleven  inspi- 
rations.   And,  that  the  abolition  of  the  natural  and  mental  func- 
tions, are  in  the  precise  ratio  to  the  loss  of  the  healthy  propor- 
tions, between  the  motions  of  the  heart,  and  the  lungs  ;  and  that 
these  functions  are  restored,  exactly  in  the  degree,  that  the  pulse 
and  the  breathing,  approach  the  natural  standard. 

818.  He  also  states  this  curious,  and  to  diagnosis,  valuable 
fact;  that  in  meningeal  apoplexy,  respiration  is  always  equal  on 
both  sides;  that  is,  the  thorax  is  equally  dilated  on  the  right  and 
left  sides,  which  is  not  the  case  in  cerebral  apoplexies.     The 
mouth  is  not  distorted;  the  body  lies  in  a  straight  line;  and  if 
the  patient  be  not  in  a  state  of  stupor,  he  will  present  both  hands — 
if  he  be  somnolent,  irritating  the  limbs  will  produce  the  same 
motions.      The  nervous  and  muscular  systems  preserve  their 
powers  on  both  sides.     Though  meningeal  apoplexies  present 
important  varieties  in  the  fluids  effused,  Mr.  S.  acknowledges, 
he  has  never  been  able  to  indicate  them  individually  from  the 
accompanying  symptoms. 

819.  The  varieties  of  meningeal  apoplexies,  are  deduced  from 
the  nature  of  the  fluid  effused;  by  the  absence  of  effusion,  and 
the  rupture  of  arteries  or  veins  in  the  brain.     Hence,  there  is, 
1st,  meningeal  apoplexy  without  effusion;  2d,  with  effusion  of 
simple  serosity;  3d,  with  sero-sanguineous  effusion;  4th,  with 
arterial   rupture,  or   aneurismal   dilatation;    5th,  with  venous 
rupture. 

820.  Dissections. — In  meningeal  apoplexy  without  effusion, 
the  pia  mater  is  thickened,  dry,  and  the  vessels  slightly  distended. 


APOPLEXY.  249 

821.  In  var.  2d,  the  arteries  and  veins  are  distended,  and 
all  the  pia  mater  is  covered  with  a  net-work  of  small  vessels — 
the  arachnoides  opaque,  thickened,  and  in  places  covered  with  a 
whitish  exudation.     The  choroid  plexus  is  generally  injured ; 
distended. 

822.  In  var.  3d,  the  alteration  very  similar  to  those  in  var. 
2d ;  but  the  arachnoides  manifestly  red  and  inflamed.  It  is  prin- 
cipally in  the  lateral  ventricles  this  irritation  is  observed. 

823.  In  var.  4th,  all  the  arteries  are  distended ;  a  rupture  is 
found  either  in  one  of  the  trunks,  or  one  of  the  branches.     A 
part  of  an  artery  may  be  aneurismal. 

824.  In  var.  5th,  the  veins  are  more  frequently  ruptured. 

825.  Whenever  coagulated  blood  is  found  between  the  mem- 
branes and  the  ventricles,  and  the  cerebral  substance  sound,  we 
may  be  certain  that  the  haemorrhage  has  been  caused  by  the  rup- 
ture of  an  artery,  or  a  vein.     Venous  rupture  frequently  occurs 
in  the  choroid  plexus.    The  meningeal  apoplexy  with  serous  ef- 
fusion is  the  most  frequent — they  are  as  seven  to  two.* 

826.  Cerebral  apoplexies  and  their  varieties. — In  describ- 
ing these,  Mr.  S.  proposes  to  solve  the  following  question: — 
"an  apoplexy  being  given,  to  determine  its  seat  by  its  symp- 
toms." 

827.  Attack. — The  attack  is  often  instantaneous,  especially 
in  men  of  plethoric  habits,  short  necks,  corpulent,  and  addicted 
to   wine  and  women.     Some  moments  before  the  attack,  the 
mind  is  more  than  usually  active.     Sometimes  a  numbness  of 
one  side,  one  side  of  the  face,  or  a  fixed  pain  in  the  head,  pre- 
cedes the  attack ;  the  tongue  is  sometimes  embarrassed ;  a  diffi- 
culty in  pronouncing  certain   letters,  or   words — rarely  stut- 
tering. 

828.  "  But  whether  the  fit  has  been  preceded  by  these  symp- 
toms or  not,  at  the  moment  of  attack,  the  face  is  coloured  in  an 

*  Dr.  Craigie,  p.  210,  differs  a  little  from  Serres  in  the  appearances  of  the 
brain  in  apoplexy.  He  says,  "  in  several  of  the  cases  in  which  blood  is  found 
in  the  ventricles  of  the  brain,  it  cannot  be  traced  to  any  other  source  save  the 
exhalants  of  the  choroid  plexus;  and  blood  may  be  shown  to  be  effused  occa- 
sionally from  the  outer  division  of  the  arachnoid  membrane,  and  also  from  that 
which  covers  the  spinal  cord.  In  each  of  these  cases,  whether  the  fluid  is 
merely  sanguinolent,  or  is  pure  blood,  it  issues  from  the  same  vessels  which,  in 
the  healthy  state  of  the  membrane,  prepare  its  proper  secretions.  No  rupture 
or  breach  can  be  recognised  by  the  most  accurate  scrutiny."  Upon  this  sub- 
ject however,  we  are  disposed  to  look  upon  Serres  as  the  better  authority;  es- 
pecially, as  Dr.  Craigie's  account,  cannot  amount  to  more  than  what  he  has 
seen,  which  of  course,  is  very  limited,  when  compared  with  the  observations 
of  the  French  pathologists  who  have  paid  a  direct  attention  to  the,  subject;  and 
who  have  had  large  hospitals  for  fields  of  observation.  It  is  therefore  proba- 
ble, as  Serres  declares,  that  there  may  be  apoplexies  with  and  without  rupture 
of  vessels. 

32 


250  APOPLEXY. 

unusual  manner;  the  cervical  and  facial  veins  swell;  the  tongue 
becomes  embarrassed;  the  sight  is  imperfect:  the  hearing  im- 
paired; the  sensibility  and  the  faculties  of  the  mind  lost — and  if 
the  patient  be  erect,  he  falls  upon  the  side  which  afterwards 
will  be  struck  with  apoplexy — this  circumstance  is  of  much 
importance  to  the  physician  when  called  to  the  patient." 

829.  "  Some  hours  after  the  attack,  if  the  brain  has  not  already 
been  destroyed  at  some  part  of  its  surface,  respiration  becomes 
slower,  the  venous  blood  suffers  a  mechanical  obstruction,  and 
requires  an  appropriate  reaction  of  the  breast.  The  pulse  is  strong, 
hard,  and  frequent — the  action  of  the  heart  increases  in  propor- 
tion to  the  difficulty  of  respiration.     The  force  and  hardness  of 
the  pulse  continue  until  the  moment  a  vessel  gives  way  in  the 
brain — it  then  becomes  suddenly  small,  concentrated,  and  fre- 
quent." 

830.  "Respiration  is  equal  on  both  sides  in  the  beginning  of 
the  attack,  but  the  thorax  and  lungs  are  unequally  dilated — one 
side  of  the  chest  becomes  motionless,  while  the  other  seems  to 
redouble  its  activity;  on  the  side  in  which  the  action  is  diminish- 
ed, the  ribs  are  flattened,  but  on  the  opposite  side  they  are  ele- 
vated; the  two  sides  thus  offering  a  very  obvious  contrast.  This 
happens  previously  to  the  occurrence  of  the  hemiplegia;  and  it 
is  important  to  attend  to  this  symptom,  as  it  points  out  the  side 
that  will  be  paralyzed." 

831.  Coma  and  stupor  extreme — sensibility  diminished  on 
both  sides ;  sometimes  remarkably  so  on  the  side  about  to  be  in- 
jured— at  other  times,  sensibility  remains,  though  paralysis  is 
about  to  take  place.  The  paralyzed  member  sometimes  preserves 
its  sensibility ;  but  when  it  loses  it,  it  is  before  the  loss  of  the 
power  of  motion. 

832.  Varieties  of  Cerebral  Apoplexy. — Observation  has  not 
furnished  us  in  cerebral  apoplexy  with  any  decided  marks  or 
symptoms  of  each  variety,  any  more  than  in  the  meningeal. 
Dissections  have  revealed  the  following  forms  of  cerebral  apo- 
plexies: 1st, cerebral  apoplexy  with  hemiplegia;  2d,  with  para- 
lysis of  one  arm ;  3d,  with  paralysis  of  one  leg;  4th,  with  double 
hemiplegia ;  5th,  with  complete  paralysis  from  a  single  attack. 

833.  "  These  apoplexies  have  distinct  and  different  seats  in 
the  brain,  as  will  be  seen  by  the  following  analysis  of  my  dissec- 
tions."    Mr.  S.  then  says, 

834.  "  I  have  openly  and  attentively  dissected  one  hundred 
and  seventy-one  subjects,  dead  of  cerebral  apoplexy,  with  hemi- 
plegia of  the  arm  and  leg  at  the  same  time;  and  I  have  found,  in 
one  hundred  and  seventy-one,  the  hemisphere  of  the  brain  on 
the  opposite  side  materially  affected  in  its  structure.    I  have  dis- 
sected the  brains  of  forty-seven  hemiplegics  dead  at  the  Hospital 


APOPLEXY.  251 

of  Pity,  and  forty-seven  times  I  found  disorganization  opposite 
to  the  palsied  side.  I  have  received,  from  the  hospitals  of  the 
Bicetre  and  Salpetfiere  and  the  Hotel  Dieu,  about. one  hundred 
and  fifty  brains  of  hemiplegic  patients,  and  always  without  ex- 
ception, the  alteration  of  the  brain  was  in  the  opposite  lobe  to 
the  paralyzed  side.  May  we  not,  after  these  facts,  and  by  the 
aid  of  two  or  three  thousand  cases  contained  in  the  annals  of 
science,  establish  it  as  a  principle,  that  the  cerebral  disorganiza- 
tion constantly  occupies  the  lobe  opposite  to  the  palsied  side,  or 
the  side  that  has  remained  hemiplegic,  during  the  cerebral  apo- 
plexy." 

835.  Double  hemiplegies  may  come  on  suddenly,  or  by  two 
distinct  attacks.    In  this  species,  the  mouth  is  not  paralyzed,  as 
is  the  case  of  single  hemiplegia.  In  both,  the  seat  is  the  same  as 
in  single  apoplexy,  with  paralysis  on  one  side;  the  two  sides  are 
successively  affected.     A  single  stroke  may  paralyze  the  whole 
body;  neither  of  the  limbs  can  be  excited  to  motion  by  any  sti- 
mulation.    In  this  case  the  extravasation  will  be  in  the  pons  va- 
rolii  or  tuber  annulare.     Death  always  follows  with  frightful 
quickness.    The  patient  dies  of  asphyxia,  or  like  animals  which 
have  had  both  pneumogastric  nerves  cut.    Such  are  the  principal 
varieties  of  cerebral  apoplexies,  and  if  "  I  mistake  not,  we  may 
prognosticate  the  seat  of  the  disease  from  the  symptoms." 

836.  In  all  instances  of  apoplexy  without  paralysis,  the  brain 
itself  is  uninjured — but  in  these  cases,  the  membranes  are  altered 
in  different  degrees ;  but  that  each  of  these  degrees  has  its  pecu- 
liar character  of  effusion.     Had  the  irritation  been  intense,  sud- 
den, and  of  short  duration ;  were  the  membranes  inflamed  par- 
tially or  universally,  the  fluid  effused  within  the  ventricles,  be- 
tween the  convolutions,  or  in  the  commencement  of  the  spinal 
canal,  was  always  found  to  be  either  sanguineous  or  sero-san- 
guineous.  This  effect  was  so  uniform,  that  the  effusion  was  only 
found  where  the  irritation  had  existed  previously — if  this  irrita- 
tion happened  to  the  ventricles  alone,  the  effusion  was  limited 
to  them;  if  upon  the  exterior  of  the  encephalon,  the  sanguineous 
fluid  was  only  found  there,  for  the  ventricles  in  such  a  case  would 
be  found  either  empty,  or  contain  nothing  but  simple  serosity. 

837.  In  apoplexies  with  paralysis,  the  disorganization  of  the 
encephalon  was  constant,  as  has  been  observed  before.    If  there 
was  nothing  fortuitous  in  these  coincidences,  Mr.  S.  says  it  is 
easy  "  to  assign  to  apoplexies  their  characters,  place,  and  name." 
The  apoplexies  without  palsy  having  their  seat  in  the  membranes, 
he  thinks  are  properly  designated  by  the  term  meningeal  apo- 
plexies; while  those  complicated  with  paralysis,  are  called  cere- 
bral apoplexies. 


252  APOPLEXY. 

838.  Our  author  denies  the  existence  of  serous  and  sanguineous 
as  separate  species;  and  insists  that  all  apoplexies  are  seated  in 
the  brain  and  its  appendages.  And  those  recorded,  purporting 
to  be  apoplexy  of  the  stomach  or  intestinal  canal  in  apoplectic 
subjects  were  accidental,  and  derived  their  supposed  existence 
from  the  irritation  or  inflammation  excited  by  the  emetics  and 
cathartics  administered  for  their  relief. 


Of  the  Treatment  of  Apoplexy. 

839.  The  treatment  of  apoplexy,  will  very  properly  divide 
itself  into  that  which  is  prophylactic ;  and  into  that,  which  is  ne- 
cessary during  the  paroxysm. 

1.  Of  the  Prophylactic  Treatment. 

840.  By  glancing  our  eye  upon  the  predisposing  causes  of  this 
disease,  it  will  be  perceived,  that  bodily  conformation,  habits, 
period  of  life,  and  temperament,  may  one  or  all  contribute  to  the 
production  of  apoplexy.   Each  of  these  conditions  has  some  mo- 
difying influence  either  upon  the  formation  or  distribution  of  the 
blood,  so  as  to  determine  it  in  an  unequal,  or  in  undue  manner, 
to  the  brain ;  consequently,  to  be  useful  to  a  constitution,  prone 
from  either,  or  all  of  these  causes  to  apoplexy,  their  agency  must 
be  counteracted  in  the  best  manner  in  our  power.   We  have  full 
belief  in  the  existence  of  an  apoplectic  constitution ;  and  of 
course,  an  entire  conviction  of  the  tendency,  of  certain  causes  to 
effect  the  transportation  of  an  undue  quantity  of  blood  to  the 
vessels  of  the  brain,  and  thus  indirectly  produce  the  disease  in 
question. 

841.  If  this  be  true,  it  will  follow,  that  all  our  means  must  be 
directed  to  the  prevention  of  the  too  great  formation  of  blood, 
or  divesting  it  from  an  unequal  distribution.     These  means  will 
necessarily  consist  in  a  proper  observance  of  diet,  in  the  judi- 
cious employment  of  exercise,  and  the  proper  administration  of 
remedies. 

842.  The  first  plan  must  be  carried  into  execution,  by  recom- 
mending a  diminished  quantity  of,  or  an  entire  abstinence  from, 
animal  food,  at  least  so  far  as  will  be  compatible  with  the  safety 
of  the  stomach,  and  the  general  strength  of  the  body.     A  diet 
consisting  chiefly,  if  not  altogether,  of  vegetables,  should  be 
rigorously  adopted.   Nothing  but  plain  water  should  be  used  for 
drink — all  distilled  or  fermented  liquors  being  absolutely  and 
directly  injurious.    But  care  should  be  taken,  in  the  selection  of 


APOPLEXY.  253 

the  quality,  as  well  as  caution  exercised,  in  the  use  of  the  quan- 
tity— for  error  may  be  committed  in  either.* 

843.  The  quality  should  be  that  of  easy  digestion;  or  of  such 
substances  as  experience  had  proved  to  be  acceptable  to  the  sto- 
mach ;  for  in  this  particular  individual  differences  will  constantly 
present  themselves.  Rice,  sago,  arrow-root,  tapioca,  barley,  oat- 
meal, potatoes,  turnips,  tomatoes,  salsafee,  parsnips,  beets,  ochres, 
and  spinage,  may  be  looked  upon  as  the  most  digestible ;  the  ripe 
fruits  of  the  season  may  also  be  indulged  in.     Cabbage,  beans, 
sallads,  raddishes,  onions,  and  cucumbers,  are  decidedly  impro- 
per, from  the  difficulty  almost  constantly  found,  in  their  assimi- 
lation.   If  animal  food  in  any  quantity  be  indulged  in,  it  should 
be  of  the  most  digestible  kind ;  or  such  as  has  been  found  by  ex- 
periment to  be  speedily  and  easily  digested.     Suppers  of  every 
kind  should  be  avoided.    "The  quantity  should  be  no  more  than 
the  stomach  can  with  facility  and  certainty  digest. 

844.  Exercise  should  be  regularly  and  steadily  pursued ;  but 
it  should  never  consist  of  such  exertions  as  have  a  tendency  to 
force  the  blood  into  the  head ;  such  as  are  proscribed  will  easily 
present  themselves  to  the  mind,  and  should  be  carefully  avoided. 
Exercise  must  never  be  performed  in  a  hot  or  even  a  warm  sun; 
nor  should  it  be  indulged  in  extremely  cold  weather  or  in  damp 
places.     Serres  recommends  exercise,  even  to  fatigue,  for  those 
disposed  to  apoplexy. 

845.  As  it  is  every  way  desirable,  that  the  circulation  should 
not  be  hurried  while  the  body  is  passive,  the  subject  should  shun 
all  crowded  places,  heated  air,  and  too  much  warmth  at  night 
from  sleeping  upon  a  feather  bed,  or  indulging  in  too  much  bed- 
covering.     He  should  sleep  in  a  well-ventilated  room ;  should 
wear  nothing  tight  round  his  neck,  or  waist.   Dr.  Donald  Monro 
says  he  has  known  soldiers  carried  off  by  apoplexy,  in  conse- 
quence of  the  stricture  of  the  veins  of  the  neck,  from  being 

*  In  certain  habits  disposed  to  apoplexy,  there  appears  to  exist  an  anormal 
sanguification — this  is  so  strongly  marked  in  some  cases,  as  to  bid  defiance  to 
abstinence  to  counteract.  We  have  seen  two  or  three  instances,  in  which  the 
most  rigid  abstemiousness  was  observed,  yet  sanguification  went  on  with  such 
certainty  and  excess  as  to  require  the  occasional  abstraction  of  blood  to  pre- 
vent the  disastrous  effects  of  repletion.  But  one  of  the  most  remarkable  cases 
of  this  kind  is  given  by  Dr.  Rees,  (on  Costiveness,  p.  162.)  He  says  that  "a 
gentleman  strongly  disposed  to  apoplexy,  though  he  avoided  animal  food  and 
stimulants,  and  selected  from  the  vegetable  kingdom  the  articles  which  afford- 
ed the  least  nutriment,  was  under  tile  necessity  of  losing  twelve  ounces  of 
blood  every  fortnight  for  many  months,  to  keep  off  a  fit  of  apoplexy,  and  within 
the  last  six  months  of  his  life  he  found  it  necessary  to  lose  the  same  quantity 
of  blood  weekly;  and  notwithstanding  active  preventive  means  were  adopted 
on  the  occurrence  of  a  symptom  of  approaching  apoplexy,  he  fell  a  sacrifice  to 
the  disease.  The  sanguiferous  system  became  overloaded,  a  vessel  of  the  brain 
gave  way,  and  the  effusion  of  blood  produced  fatal  apoplexy." 


254  APOPLEXY. 

obliged  to  wear  their  cravats  too  tight.  Winslow  has  also  men- 
tioned the  same  thing.*  Dr.  Fothergill  mentions  the  ease  of  a 
gentleman  who  was  predisposed  to  apoplexy  being  seized  with 
a  fit,  by  turning  his  head  too  far  round  to  look  at  an  object  rather 
behind  him.t  Now  this  position  of  the  head  could  only  have 
been  mischievous  by  interrupting  the  descent  of  the  blood  from 
the  head  ;  acting  as  a  partial  ligature. 

846.  The  utmost  care  should  be  taken  against  the  suppression 
of  any  habitual  evacuation  ;  and  if  it  happen,  we  should  attempt 
its  restoration  as  quickly  as  possible,  and  by  the  best  means  in 
our  power.     The  menstrual  evacuation,  if  arrested,  should  be 
recalled  by  the  appropriate  remedies ;  the  haemorrhoidal  flux,  if 
interrupted,  should  be  compensated  for  by  the  application  of 
leeches  to  the  anus;  issues,  or  setons  if  they  dry  up,  should  be 
renewed,  &c. 

847.  Bathing  the  head  with  cold  water  daily,  would  be  a  very 
good  practice  with  persons  of  apoplectic  tendencies — the  hair 
should  be  kept  cut  short ;  the  direct  rays  of  the  sun  should  be 
reflected  by  a  white  hat ;  and  the  feet  kept  warm  constantly.     If 
the  feet  be  habitually  cold,  the  partial  warm  bath  with  the  flour 
of  mustard  in  it,  should  be  used,  whenever  they  feel  uncomfort- 
ably cold,  on  going  to  bed. 

848.  It  may,  in  addition  to  the  means  just  suggested,  be  im- 
portant to  employ  remedies,  for  the  immediate  diminution  of 
blood,  and  for  the  proper  regulation  of  the  bowels.  For  the  first, 
the  occasional  loss  of  a  few  ounces  of  blood  will  be  highly  ser- 
viceable— this  may  be  done  by  bleeding  from  the  arm,  or  by  ab- 
stracting blood  from  the  head  by  cups  or  leeches;  or  according 
to  Serres,  from  the  anus,  by  the  latter  means. 

849.  Costiveness  should  be  very  carefully  guarded  against, 
either  by  diet,  or  medicine ;  or  if  necessary  by  both.     For  the 
first  means,  the  bran  bread  should  be  used  freely  instead  of  other 
bread ;  ripe  fruits,  prunes,  figs,  &c.     For  the  second,  the  aloetic 
and  rhubarb  pill  will  answer  admirably,  (see  p.  93.)    It  may  be 
proper  also  to  purge  occasionally,  especially  if  there  be  slight 
head-ache,  unquiet  nights,  and  confined  bowels.     The  patient 
when  in  bed,  should  not  fail  to  sleep  with  his  head  high,  and 
uncovered  by  night-cap  or  handkerchief. 

2.   Treatment  during  the  Paroxysm. 

850.  As  it  is  agreed  on  all  hands,  that  in  apoplexy,  there  is 
an  excess  of  blood  occupying  the  vessels  of  the  brain,  or  a  quan- 

*  Cooke  on  Nervous  Disorders,  Vol.  I.  p.  227. 
f  Works,  p.  214.  Vol.  III. 


APOPLEXY.  255 

tity  extravasated  in  either  its  cavities  or  substance,  it  would  seem 
to  follow  as  a  necessary  consequence,  that  nothing  can  take  off 
the  pressure  caused  by  the  distended  vessels,  or  remove  the  dis- 
tention  from  them,  but  a  reduction  of  the  quantity  of  this  fluid  ^ 
and  consequently,  that  our  main  dependence  for  this  effect,  must 
be  by  blood-letting.  By  this  it  will  be  perceived,  that  we  re- 
nounce the  distinction  made  by  systematic  writers,  of  "sangui- 
neous" and  "serous  apoplexy,"  though  "educated"  in  its  belief. 
We  think  indeed  that  no  one  will  retain  the  distinction  after  a 
careful  and  dispassionate  perusal  of  Serres's  memoir  upon  this 
subject.  Indeed  the  learned  editor  of  the  Medico-Chirurgical 
Review,  calls  it  an  ignis  fatuus,  though  he  does  not  feel  himself 
authorized  "to  treat  all  cases  of  apoplexy  in  the  same  manner." 

851.  Notwithstanding  our  conviction  of  the  absolute  neces- 
sity of  blood-letting  in  this  disease,  we  are  convinced,  that  both 
time  and  quantity  must  be  regarded.      With  regard  to  time. 
It  sometimes  happens  immediately  after  the  apoplectic  stroke, 
that  the  powers  of  the  system  are  very  much  prostrated,  from 
the  sudden  violence  committed  on  the  nervous  system;  the  face 
is  pale  ;  the  skin  and  extremities  cold  ;  the  respiration  slow  and 
difficult ;  the  pulse  feeble  and  frequent,  while  both  faeces  and 
urine  may  be  discharged  involuntarily.     Now,  it  must  be  evi- 
dent, that  if  we  prescribe  for  the  name  of  the  disease,  to  the  to- 
tal disregard  of  the  state  of  the  circulatory  system,  we  should  do 
much  mischief,  by  the  abstraction  of  blood. 

852.  It  may  be  said,  that  this  appearance  is  fallacious ;  and 
that  the  system  is  merely  depressed,  (see  note  to  par.  352,)  and 
that  it  will  rise,  if  we  take  blood  from  it — this  may  be  the  case 
sometimes  for  aught  we  know ;  but  we  have  never  seen  a  case 
attended  by  the  symptoms  above  detailed,  especially  in  subjects 
advanced  in  life,  in  which  the  pulse  was  in  a  state  of  depression 
agreeably  to  the  notions  we  have  of  that  state  of  the  arterial  sys- 
tem.    In  cases  of  the  kind  under  consideration,  we  have  never 
ventured  to  abstract  blood  until  we  have  enabled  the  system  to 
react,  by  the  use  of  external  stimuli.     We  therefore  direct  the 
legs  and  feet  to  be  placed  if  possible  in  warm  water,  in  which 
there  is  a  considerable  quantity  of  the  flour  of  mustard  mingled. 
These  parts  are  to  be  well  rubbed  with  the  hand  whHe  in  the 
water  for  ten  or  fifteen  minutes;  they  are  then  to  be  dried  and 
wrapped  in  a  warm  blanket.   Dr.  Abercrombie  speaks  highly  of 
strong  frictions  applied  to  the  body. 

853.  Should  it  not  be  practicable  to  place  the  feet  and  legs  in 
water  as  directed,  these  parts  should  be  bathed  with  brandy  and 
mustard  or  Cayenne  pepper,  until  a  rubefacient  effect  is  produced. 
At  the  same  time  mustard  and  vinegar  or  brandy,  should  be  ap- 
plied warm,  to  each  forearm  until  they  redden  the  skin;  and  the 


256  APOPLEXY. 

whole  body  should  be  warmed  by  heated  blankets,  bricks,  or  jugs 
of  water.  And  if  by  these  means  reaction  is  established,  then, 
and  not  until  then,  should  we  open  a  vein.  But  as  soon  as  this 
has  taken  place,  blood  should  be  abstracted,  with  a  freedom  and 
to  an  extent  commensurate  with  the  powers  of  the  system  and 
the  urgency  of  the  paroxysm.  It  is  impossible  to  give  a  definite 
direction  as  regards  the  quantity  of  blood  that  should  be  drawn 
at  any  one  time,  or  during  the  course  of  the  disease,*  as  this 
must  depend  upon  the  effects  of  that  which  is  abstracting,  or 
has  been  abstracted,  upon  the  force  of  the  symptoms,  and  the 
power  of  the  pulse;  remembering  always,  that  bleeding  is  per- 
formed to  no  valuable  purpose,  if  it  be  not  carried  to  an  extent 
that  will  diminish  the  vigour  of  the  arterial  system. 

854.  In  order  however  to  ensure  this  desirable  end,  at  the 
least  possible  expenditure  of  blood,  it  should  be  abstracted  from 
a  large  vessel,  and  from  a  large  orifice,  and  in  as  short  a  time  as 
may  be  practicable.     For  this  purpose  the  jugular  vein  or  veins 
are  opened,  sometimes,  with  great  advantage — we  say,  some- 
times ;  because  this  cannot  always  be  done.     If  this  vein  be  se- 
lected, it  must  be  opened  without  the  use  of  a  ligature ;  as  this 
would  be  mischievous,  by  retarding  the  departure  of  blood  from 
the  head.     We  have  never  found  it  necessary  to  do  more,  than 
to  compress  the  vein,  by  the  extremity  of  a  finger. 

855.  If  the  jugular  cannot  be  commanded,  we  should  bleed 
from  the  arm  or  arms,  making  large  orifices,  as  just  recommended. 
To  aid  the  bleeding,  we  should  have  the  bowels  opened  as  speedily, 
and  as  copiously, as  possible;  this  should  be  attempted  by  an  injec- 
tion made  of  two  ounces  of  senna  and  a  pint  of  boiling  water;  and 
dissolving  in  it,  after  straining  it,  a  table-spoonful  of  common 
salt.  This  must  be  repeated,  from  time  to  time,  until  the  bowels 
are  freely  purged.  If  the  patient  be  capable  of  swallowing,  which 
is  often  the  case,  an  infusion  of  senna  of  the  strength  just  re- 
commended for  the  injection,  should  be  given  him  frequently 
by  spoonfuls  until  the  object  for  which  it  is  given  is  accom- 
plished.    We  prefer  the  senna  to  any  other  of  the  cathartic  re- 
medies ;  as  it  is  always  certain  and  prompt,  if  the  sensibility  of 
the  alimentary  canal  be  not  too  much  diminished,  as  is  the  case, 
sometime!.     Indeed  the  griping  effect  of  the  senna  appears  to  be 
useful  in  all  the  affections  of  the  brain,  that  depend  upon  its  re- 
pletion. 

856.  Cold  applications  should  be  made  from  time  to  time, 
under  the  precautions  suggested,  (par.  533,)  for  their  employ- 

•  Dr.  Cheyne  says,  "  it  ought  to  be  known  that  from  six  to  eight  pounds  of 
blood  have  been  taken  from  a  person  by  no  means  robust,  before  the  disease, 
which  ended  favourably,  began  to  yield." 


APOPLEXY.  257 

ment  in  fever.*  The  feet  and  legs  should  never  be  permitted  to 
remain  cold  an  instant,  provided  they  can  be  made  warm  by  ar- 
tificial means.  The  patient  should  be  placed  in  as  an  erect  a  po- 
sition as  possible,  as  every  advantage  should  be  taken  of  the  be- 
nefit gravitation  affords  us. 

857.  As  respects  the  propriety  of  repeating  the  bleeding, 
much  must  be  left  to  the  discretion  of  the  medical  attendant — 
for  he  must  determine  whether  the  state  of  the  pulse  and  other 
symptoms  will  justify  the  further  abstraction  of  blood.  Should  it 
not  be  thought  justifiable  to  bleed  from  the  arm,  yet  the  symp- 
toms persist,  much  advantage  may  be  derived  from  local  deple- 
tion; especially  by  cups — six,  eight,  or  ten  ounces  may  be  rea- 
dily abstracted  by  these  means  from  the  temples,  forehead,  or 
behind  the  ears  and  neck.     Cupping  is  preferable  to  leeches, 
though  we  could  abstract  an  equal  quantity  of  blood  by  their  ap- 
plication. Why  this  is  so,  is  perhaps  difficult  to  explain — but  all 
experience  seems  to  confirm  it  as  a  truth.     Dr.  Abercrombie 
seems  to  attach  but  little  importance  to  local  bleeding;  at  this  we 
are  not  a  little  surprised ;  while  Dr.  Gregory,  we  are  informed 
by  Dr.  Johnstone,  used  to  declare  in  his  lectures,  he  had  seen 
the  cupping-glasses  rouse  the  patient,  when  general  bleeding 
had  produced  no  effect. 

858.  Of  this  fact  we  do  not  entertain  a  doubt ;  yet  if  it  be  re- 
ceived as  it  stands,  as  a  practical  lesson,  it  might  grossly  mislead 
the  inexperienced  practitioner;  for  it  appears  to  imply,  what  we 
presume  Dr.  Gregory  did  not  mean  should  be  understood  by  the 
observation, — namely,  that  cupping  was  preferable  in  apoplexy 
to  general  bleeding;  and  that  it  would  succeed,  where  this  had 
failed.     The  fact  therefore  should  only  be  thus  interpreted,  that 
by  the  general  bleeding,  a  sufficient  quantity  to  relieve  the  pa- 
tient had  not  been  drawn ;  but  the  additional  abstraction  of  a 
few  ounces  by  cupping,  effected,  just  what  was  left  undone,  by 
the  previous  bleedings.     For  we  will  persist  in  the  belief,  that 
had  not  just  so  much  blood  been  drawn  by  the  general  bleeding, 
that  the  local  bleeding  would  not  have  been  of  the  slightest  avail. 
Indeed,  topical  bleeding  should  never  be  had  recourse  to,  but 
after  it  was  no  longer  proper  to  bleed,  generally. 

859.  Of  emetics  in  apoplexy,  we  can  say  nothing  from  our 
own  experience,  never  having  had  courage,  (from  a  precon- 
ceived notion  we  grant,)  to  employ  them.     Nor  have  we  been 
seduced  by  all  that  has  been  said  in  their  favour,  by  an  inge- 

*  Cold  water  in  a  full  stream  upon  the  crown  of  the  head,  and  received  in  a 
basin  held  under  the  chin,  is  recommended  by  Dr.  Abercrombie  in  apoplexy. 
He  gives  an  instance  of  a  girl,  who  was  quickly  restored  by  this  means,  from  a 
state,  he  believed  to  be,  perfect  apoplexy. 

33 


258  APOPLEXY. 

nious  writer  in  the  6th  and  7th  vols.  of  the  Medical  and  Phy- 
sical Journal.  To  us  there  appears  to  be  but  one  possible  case 
in  which  they  can  be  employed  with  the  probability  of  advan- 
tage, and  that  is  in  crapulous  apoplexy ;  and  even  here,  we 
would  not  venture  upon  giving  them,  but  after  pretty  ample  de- 
pletion. 

860.  Every  thing  that  can  act  round  the  neck  like  a  ligature, 
should  be  instantly  removed  ;  nor  should  they  be  suffered  to  be 
reapplied  while  the  disease  continues.     The  patient  should  be 
placed  in  as  airy  a  situation  as  circumstances  will  permit;  and 
constantly  kept  in  as  moderate  a  temperature  of  atmosphere  as 
can  be  commanded. 

SECT.  III. — PARALYSIS  OR  PALSY. 

861.  The  disease  under  consideration,  with  several  others, 
seem  to  prove,  that  every  sublunary  good  is  attended  by  a  cor- 
responding evil.     The  high  order  of  mind  granted  to  man,  sub- 
jects him  to  evils,  to  which  the  humble  and  subordinate  brute 
is  exempt.     The  display  of  his  intellectual  faculties,  or  the  ex- 
ercise of  his  social  virtues,  subject  the  organ  from  which  these 
benefits  arise,  to  a  variety  of  diseases.     Among  the  most  serious 
of  these,  are  mental  alienation,  apoplexy,  epilepsy,  and  palsy. 
The  brain,  though  transcendent  in  power,  is  nevertheless  most 
delicate  and  frail  in  structure ;  and  though  destined  to  endure 
much,  it  is  nevertheless  most  vulnerable;  and   when  it  suffers 
lesions,  the  penalties  are  in  proportion  to  the  high  destinies  this 
organ  has  to  fulfil. 

862.  The  disease  now  to  be  described,  is  not  one  of  the  least 
of  the  evils  to  which  the  brain  and  nervous  system  are  liable — 
though  less  dangerous  than  apoplexy,  it  is  infinitely  more  per- 
manent, and  thus  perhaps  becomes  the  greater  evil;  for  it  is  not 
only  followed  by  physical  inability,  but  by  serious  moral  evils 
and  disqualifications. 

863.  The  male  is  more  liable  to  this  disease  than  the  female; 
is  this  owing  to  less  predisposition  in  the  female,  or  to  the  greater 
exposure  of  the  male  to  its  causes?     The  latter  is  the  more  pro- 
bable, as  the  male,  from  his  peculiar  and  unalienable  habits,  must 
necessarily  incur  a  greater  share  of  risk  ;  and  we  may  safely  add, 
his  artificial,  or  voluntary  habits,  also  subject  him  to  the  same 
liabilities;  thus  his  high  and  luxurious  living  causes  plethora, 
and  plethora  causes  apoplexy,  and  consequently  palsy. 

864.  We  say  consequently  palsy;  for  when  idiopathic,  it  is 
only  a  "minor  apoplexy."     Dr.  Gregory  however  asserts,  that 
"it  will  be  found  in  practice,  that  palsy  is  much  more  com- 


PARALYSIS.  259 

monly  the  precursor,  than  the  consequence  of  apoplexy."*  To 
this  we  cannot  assent,  and  for  this,  to  us,  sufficient  reason,  that 
we  have  never  observed  the  order  spoken  of  by  Dr.  Gregory; 
for  every  distinctly  recollected  instance  of  idiopathic  palsy, 
had  been  preceded  by  apoplexy,  or  some  lighter  cerebral  affec- 
tion; but  we  cannot  name  a  single  instance  of  the  converse  of 
this  position,  though  we  are  far  from  denying  that  it  has  occur- 
red. We  have  seen  an  entire  restoration  of  the  mental  powers, 
after  apoplexy,  though  it  was  followed  by  hemiplegia ;  and  one 
of  these  instances,  a  few  days  since,  proved  fatal  in  about  forty- 
eight  hours,  by  an  effusion  of  water  in  the  chest;  the  patient  was 
sensible,  to  within  five  minutes  or  less,  of  his  decease.  We  shall 
therefore  refer  the  reader  to  what  we  have  said  on  the  causes 
and  pathology  of  apoplexy,  (p.  242,  et  seq.)  as  they  will  strictly 
explain,  what  relates  to  the  production  and  consequences  of  idio- 
pathic palsy ;  for  the  latter  is  only  the  sequence  of  the  former. 

865.  Yet  there  are  circumstances  connected  with  the  pheno- 
mena of  palsy  that  are  both  curious  and  important  in  patholo- 
gical and  therapeutical  points  of  view — namely,  and  especially, 
the  loss  of  power  in,  or  the  controul  over,  the  voluntary  muscles 
of  the  part  affected,  yet  leaving  their  sensibility   unimpaired ; 
while  on  the  other  hand,  there  may  be  a  total  loss  of  sensibility, 
with  an  entire  command  of  the  muscles  of  the  part  affected. 

866.  "  This  curious  fact/'  says  Dr.  Gregory,  "  has  perplexed 
physiologists  in  all  ages ;  and  various  theories  have  been  offered 
in  explanation  of  it.     In   the  present  state  of  our  knowledge, 
however,  regarding  the  functions  of  the  brain  and  nerves,  they 
must  be  considered  as  altogether  hypothetical." 

867.  Why  all  that  has  hitherto  been  said  with  a  view  to  elu- 
cidate this  seemingly  inexplicable  phenomenon,  should  be  look- 
ed upon  as  hypothetical,  in  the  opinion  of  Dr.  Gregory,  we  are 
at  a  loss  to  determine ;  since  Mr.  Charles  Bell  has  clearly  shown 
that  for  the  purposes  of  muscular  motion,  and  of  sensation, 
there  are  separate  and  distinct  nerves ;  and  from  what  he  has 

*  Dr.  Potter,  one  of  the  editors  of  Dr.  Gregory's  work  in  this  country,  makes 
the  following1  correct  observations;  "  we  may  imagine  this  position  will  be  re- 
versed, when  we  shall  have  made  ourselves  acquainted  with  the  pathology  of 
apoplexy.  Hemiplegia  can  only  be  the  effect  of  the  want  of  that  sensorial 
power,  which  is  distributed  to  the  nerves  from  the  brain  in  health ;  and  al- 
though all  the  more  prominent  symptoms  of  apoplexy  may  not  be  present, 
the  paralysis  clearly  demonstrates,  that  there  must  have  been  some  injury  done 
to  the  nerves  at  their  origin,  which  disabled  them  in  the  performance  of  their 
ordinary  functions.  If  we  do  not  adopt  this  theory,  we  are  not  able  to  account 
for  the  state  of  the  nerves  in  which  palsy  consists.  We  observe  many  instances 
of  palsy  preceded  by  slight  affections  of  the  brain;  but  in  all  such  cases,  if  we 
had  examined  the  state  of  the  circulation,  we  should  have  discovered  a  tense 
pulse,  a  furred  tongue,  and  a  great  molestation  of  the  sensorium." — Gregory's 
Practice  of  Physic,  Vol.  II.  p.  45. 


260  PARALYSIS. 

very  clearly  demonstrated  upon  this  subject,  there  can  be  no 
mystery  in  the  insulated  sufferings  of  nerves;  for  though  tied  up 
together  in  the  same  fasciculus,  they  act  as  independently  of  each 
other,  as  though  they  were  widely  separated.  As  Mr.  Bell's 
views  of  the  independent  functions  of  nerves  are  highly  interest- 
ing, and  may  be  altogether  new  to  many,  we  will  give  his  ac- 
count of  them  in  his  own  words. 

868.  "  In  the  view  which  I  have  taken  of  the  nerves  of  the 
human  body,  there  are  besides  the  nerves  of  vision,  smell,  and 
hearing,  four  systems  combined  into  a  whole.     Nerves  entirely 
different  in  function  extend  through  the  frame;  those  of  sensa- 
tion; those  of  voluntary  motion;  those  of  respiratory  motion ; 
and  lastly,  nerves  which  from  their  being  different  in  the  quali- 
ties that  distinguish  the  three  others,  seem  to  unite  the  body 
into  a  whole,  in  the  performance  of  the  functions  of  nutrition, 
growth,  and  decay,  and  whatever  is  directly  necessary  to  animal 
existence." 

869.  "  These  nerves  are  sometimes  separate,  sometimes  bound 
together;  but  they  do  not  in  any  case  interfere  with  or  par- 
take of  each  other's  influence." 

870.  From  these  statements,  no  difficulty  seems  to  arise  in 
the  explanation  of  the  phenomena  presented  in  hemiplegia,  or 
other  palsies ;  for,  as  above  hinted,  that  portion  of  the  medulla 
oblongata  or  other  portions  of  the  brain,  or  nervous  system,  may 
suffer  a  lesion,  that  shall  implicate  the  nerves  of  motion,  or  of 
sensation,  or  of  both.      Generally  speaking  however,  it  is  the 
nerves  of  motion  that  are  principally  affected ;  while  the  integrity 
of  those  of  sensation  may  remain  perfect,  or  even  a  little  exalted, 
as  is  proved  by  formication,  the  action  of  blisters,  &c. 

871.  The  loss  of  sensation  is  much  more  rare;  but  we  are  not 
without  some  remarkable  instances  of  this  kind,  one  of  which  is 
recorded  in  the  Memoires  de  1'Academie  des  Sciences,  for  1743. 
A  soldier,  after  having  lost  accidentally  all  sensibility  in  the  left 
arm,  continued  to  exercise  with  the  same  freedom  as  ever;  so 
that  he  was  enabled  to  continue  the  manoeuvres  with  his  gun. 

872.  The  loss  of  sensibility,  or  of  the  power  of  voluntary  mo- 
tion, are  almost  the  only  phenomena  presented  by  a  paralyzed 
limb;  though  occasionally  we  see  a  swelling  or  oedema,  in  both 
the  hand,  arm,  foot,  and  leg  of  the  affected  side.     The  pulse  is 
said  to  be  weaker  in  the  paralytic  side,  than  in  the  well  side—- 
this might  be  taken  for  granted  at  first  sight  by  some ;  yet  it 
must  not  be  too  hastily  admitted,  for  there  is  much  difficulty  in 
making  the  comparison ;  for  as  happens  with  almost  every  body, 
the  artery  is  strongest  in  the  right  arm  of  a  right-handed  person, 
and  the  reverse ;  therefore  there  is  much  doubt  on  this  subject, 
nor  can  it  be  established  with  any  certainty  either  one  way  or 


PARALYSIS.  261 

the  other,  nor  is  it  of  any  consequence,  except  as  a  physiologi- 
cal fact. 

873.  Another  remarkable  circumstance  arises  with  respect  to 
palsy,  which  is,  that  the  lesion  in  the  brain  is  always  found  on 
the  opposite  side  to  the  paralysis.    This  also  appears  to  admit  of 
explanation,  from  the  late  discoveries  in  the  anatomy  and  phy- 
siology of  the  brain  and  nervous  system ;  though  it  has  puzzled 
physiologists  from  the  time  of  Hippocrates,  almost  to  the  pre- 
sent moment.     For  what  was  conjectured  with  regard  to  the 
decussation  of  nervous  fibres,  by  Aretasus,  (Gregory,)  has  been 
confirmed  by  late  and  accurate  observation. 

874.  Dr.  Gregory  says,  "the  principle  of  decussation  seems 
to  be  generally  admitted ;  but  the  difficulty  consists  in  determin- 
ing its  seat;  some  placing  it  in  the  corpus  callosum,  others  in  the 
tuberculum  annulare,  the  medulla  oblongata,  or  the  medulla  spi- 
nal is."     If  this  be  offered  as  an  objection  to  the  doctrine  of 
decussation,  it  is  but  a  feeble  one ;  since  if  either  of  these  parts 
be  the  seat,  it  is  every  way  sufficient  to  account  for  the  pheno- 
menon of  the  lesion  in  the  brain  being  on  the  opposite  side  to 
the  paralysis;  and  if  it  be  essential  to  point  out  one  of  these  parts, 
we  would  name  the  medulla  oblongata,  in  which  it  has  been 
traced  beyond  objection,  (Horner. ) 

875.  Indeed  it  would  seem  from  the  researches  of  Bouillaud, 
that  injury  happening  to  different  portions  of  the  brain  will  give 
rise  to  different  phenomena,  and  especially  to  the  different  par- 
tial palsies.     Thus  he  says,  1st.  When  palsy  happens  to  the  or- 
gans of  speech,  it  is  the  anterior  lobules  of  the  brain  that  is  in- 
jured.   3d.  When  the  palsy  happens  to  the  inferior  extremities, 
the  middle  lobules,  or  the  corpora  striata  is  concerned.     This 
opinion  he  says  is  nearly  the  same  as  that  entertained  by  Sauce- 
rotte  and  of  MM.  Foville,  Pinel,  Grandchamps,  and  Serres. 
3d.  When  this  disease  is  seated  in  the  upper  extremities,  the 
optic  thalami,  or  the  posterior  lobules,  is  in  fault,"  &c.     Traite 
Chirurgie  et  Physiologique  de  PEncephalite,  &c.  pp.  276-8. 

876.  This  author  appears  to  have  ascertained  pretty  satisfac- 
torily the  connexions  just  stated,  and  especially  the  first,  as  he 
has  given  a  number  of  facts  in  support  of  them.    It  however  yet 
remains  perhaps  an  uncertainty,  how  far  these  observations  tend 
to  enlighten  us  in  the  treatment  of  palsy — the  most  important 
object,  of  our  studies  and  researches ;  but,  because  we  cannot  at 
the  present  moment  turn  them  to  advantage,  we  are  not  to  lose 
sight  of  them,  as  they  may  by  and  by  be  of  the  greatest  practi- 
cal value. 

877.  The  temperature  of  the  paralytic  limb,  is  not  so  uniform 
as  in  health,  as  might  be  reasonably  supposed,  when  we  consider 
the  probable  agency  of  the  nervous  system  in  the  production  of 


262  PARALYSIS. 

animal  heat.  And  it  might  offer  some  novel  views  of  this  pro- 
cess, could  it  be  determined  by  well-directed  experiments,  in 
which  state  of  the  limb,  animal  heat  is  most  extensively  evolved; 
whether  when  it  is  deprived  of  its  sensation,  or  of  its  locomotive 
powers;  or  whether  this  process  is  affected  equally  in  either  of 
these  situations. 

878.  Mr.  Earle*  is  of  opinion,  that  there  is  a  considerable  de- 
crease of  heat  in  a  paralytic  limb,  as  they  appear  to  be  disquali- 
fied from  preserving  a  fixed  or  uniform  temperature ;  that  they 
are  much  disposed  to  acquire  the  heat  of  communication,  and 
that  they  are  injured  by  a  degree  of  it,  that  would  not  be  hurtful 
to  a  sound  limb. 

879.  The  natural  and  vital  functions  are  for  the  most  part  but 
little  injured  in  hemiplegia,  if  we  except  perhaps  a  little  tardi- 
ness of  the  bowels — but  this  is  not  by  any  means  constant.    We 
have  at  this  time,  an  aged  hemiplegic  patient,  whose  bowels  are 
most  perfectly  regular,  though  not  able  to  take  the  least  exer- 
cise. This  case  was  preceded  by  an  apoplexy  of  moderate  force, 
and  short  continuance.     Some  of  the  features  are  wont  to  suffer 
in  this  species  of  palsy,  especially  the  mouth,  and  occasionally 
the  eyes.   In  the  case  just  alluded  to,  the  mouth  was  much  drawn 
aside  at  first,  the  eye  was  swelled,  and  in  a  strong  light  there 
was  slight  strabismus.  The  mouth,  in  the  course  of  a  few  months, 
was  restored  nearly  to  its  natural  condition,  but  the  affection  of 
the  eye  continues.  In  consequence  of  the  affection  of  the  mouth, 
most  paralytics  slaver  or  drivel  very  much  from  the  injured  side; 
and  the  same  want  of  power  to  retain  the  saliva,  disqualifies  them 
from  swallowing  liquids.    The  speech  becomes  indistinct  almost 
always,  to  a  certain  extent;  and  almost  all  paralytics  find  some 
words  of  more  difficult  utterance  than  others.  The  tongue,  when 
thrust  forward,  becomes  curved  or  inclined  to  one  side,  in  con- 
sequence of  the  unequal  powers  of  its  muscles. 

880.  It  is  rare  for  the  patient  to  retain  his  mental  faculties  in 
their  full  vigour;  they  gradually  fail,  even  to  extinction  some- 
times— but  to  this  there  are  exceptions;  for  in  the  instance  al- 
ready noticed,  we  have  never  been  able  to  observe  the  slightest 
change;  the  same  powers  of  reasoning,  the  same  happy  choice 
of  words,  the  same  precision  in  the  order  of  his  business ;  and 
the  same  amenity  and  gentleness  of  manners,  as  has  ever  charac- 
terized his  best  health. 

Prognostic. 

881.  Unpromising  as  appearances  almost  always  are  in  hemi- 
plegia, instances  now  and  then  occur  of  entire  recovery.     I.  M. 

*  Medico-Chirurgical  Transactions,  Vol.  VII.  p.  179. 


•  PARALYSIS.  263 

aged  sixty  years,  had  hemiplegia  to  follow  a  slight  apoplectic 
attack — his  left  eye,  the  side  of  his  mouth,  and  tongue  were  ap- 
parently more  affected  than  the  side ;  that  is,  he  could  not  speak 
to  be  understood ;  the  eye  was  nearly  closed ;  the  eyelids  consi- 
derably swelled  ;  the  tongue  protruded  a  little  beyond  the  lips; 
and  the  saliva  flowed  incontinently  from  the  mouth.  All  mus- 
cular power  was  not  destroyed,  as  he  could  move  both  the  leg 
and  the  arm  a  little,  by  a  very  strong  exertion  of  the  will.  He 
remained  for  a  few  weeks  without  much  alteration  ;  he  now  how- 
ever began  to  show  signs  of  amendment;  by  the  oedema  leaving 
the  eyelids,  and  the  eye  itself  resuming  its  natural  appearance; 
his  mouth  becoming  straighter,  and  retaining  the  saliva  better ; 
the  tongue  began  to  perform  its  offices  with  more  success,  for 
he  could  now  articulate;  and  the  arm  and  leg  obeyed  the  will  to 
a  certain  extent,  though  very  imperfectly.  After  this,  his  im- 
provement was  no  less  rapid  than  secure ;  for  there  was  no  threat- 
ening of  relapse,  and  at  the  end  of  a  year,  he  was  perfectly  re- 
lieved, and  remains  so  to  this  time.  His  recovery  is  so  perfect, 
that  no  one  unacquainted  with  his  former  situation,  would  for  a 
moment  discover  that  he  had  ever  been  paralytic.  He  is  now 
nearly  seventy  years  of  age,  and  is  obliged,  from  the  nature  of 
his  avocation,  to  walk  several  miles  daily. 

882.  This,  however,  it  must  be  confessed,  is  a  rare  case — as 
for  the  most  part,  the  "  stroke,"  as  it  is  called,  is  more  commonly 
repeated,  than  recovery  to  ensue;  /or  against  a  repetition,  there 
seems  to  be  no  absolute  security ;  for  this  may  take  place  as  sud- 
denly as  unexpectedly,  and  prove  fatal  in  the  instant.    At  other 
times,  the  improvement  is  extremely  slow ;  and  seems  to  arrive 
to  a  certain  point,  from  which  it  never  stirs;  in  this  case,  the 
patient  may  drag  on  for  many  years,  a  miserable  existence;  and 
is  at  last  perhaps  carried  off  by  apoplexy. 

Paraplegia. 

883.  By  this  term  we  understand  the  entire  loss  of  power 
of  the  lower  half  of  the  body.     This  species  of  palsy  is  less  fre- 
quent, though  more  disastrous  than  hemiplegia;  the  urine  flows 
involuntarily;  the  sphincter  ani  cannot  retain  the  fasces  when 
they  are  urged  into  the  rectum,  and  consequently  both  are  dis- 
charged without  the  power  to  prevent  them,  or  perhaps  the  con- 
sciousness that  it  has  taken  place. 

884.  This  species,  like  the  one  just  considered,  Dr.  Baillie 
has  shown,  may  depend  upon  some  pathological  change  in  the 
brain,  like  that  causing  hemiplegia.     This  complaint  is  usually 
slower  in  its  march  than  hemiplegia;  a  numbness  or  stiffness  in 
the  lower  limbs  are  first  felt ;  but  by  and  by  the  patient  is  unable 


264  PARALYSIS. 

to  walk,  or  to  support  himself,  soon  after  which,  the  distressing 
symptoms  above  mentioned,  are  found  to  follow;  and  after, 
(sometimes,)  a  long  period  of  suffering,  the  patient  dies;  but  this 
is  more  frequently  from  exhaustion,  than  from  a  renewal  of  the 
"stroke." 

885.  We  are  told,  that  dissections  have  proved,  that  cere- 
bral lesions  have  been  found  in  this  disease,  as  well  as  in  hemi- 
plegia.     And  Dr.  Baillie  says,  he  has  known  it  to  be  preceded 
by  head-ache,  drowsiness,   impaired  vision,  loss  of  memory, 
dropping  of  the  eyelids,  and  eventually  a  loss  of  power  in  the 
lower  extremities.     Few  recover  from  paraplegia. 

886.  There  are  a  number  of  local  or  mechanical  causes  enu- 
merated by  authors  as  having  produced  paraplegia ;  as  a  diseased 
spine  produced  by  a  mechanical  cause;  incurvations  from  scro- 
fula or  rickets;  inflammation  of  the  covering  or  the  substance  of 
the  nerve;  irritation  of  the  bowels,  &c. 

Partial  Palsies. 

887.  Notwithstanding  the  progress  that  pathology  has  made, 
and  is  now  daily  making,  there  are  many  things  connected  with 
the  affections  of  the  brain  and  nervous  system,  that  are  extremely 
difficult,  if  susceptible  of  explanation  in  our  present  state  of 
knowledge.     Hence  many  instances  of  partial  paralysis  do  not 
appear  capable  of  an  explanation,  by  referring  their  causes  to 
lesions  of  either  the  brain  or  spinal  marrow,  or  to  local  causes, 
as  far  as  can  be  detected  by  any  anatomical  change  of  structure. 
We  are  therefore  obliged  to  admit  that  the  cause  of  palsy  is 
sometimes  inscrutable. 

888.  Palsy  of  a  partial  kind  has  followed  falls,  blows,  or  so- 
lution of  continuity;  it  has  been  produced  by  pressure  upon  an 
individual  nerve,  as  by  a  ligature,  tumours,  fractures,  luxations, 
by  serous,  sanguine,  or  purulent  effusions.     Plethora  alone  has 
been  said  to  give  rise  to  palsy ;  the  suppression  of  accustomed 
evacuations  of  any  kind;  excessive  purging;  intemperate  use  of 
spirituous  liquors ;  narcotic,  acrid,  corrosive  substances  taken  into 
the  stomach;  emanations  from  lead,  mercury,  and  arsenic;  ener- 
vating pleasures;  fits  of  passion;  grief;  disappointment;  frights; 
or  other  severe  exercises  of  the  mind,  &c.  &c. 

889.  Now  it  is  not  difficult  to  perceive  or  understand  how 
some  of  these  causes  may   induce  partial  palsy ;  but  others  are 
beyond   explanation    in  the   present  state  of  our  knowledge. 
The  action  of  any  of  the  mechanical  agents  just  enumerated,  can 
be  readily  understood,  when  they  are  brought  to  act  in  a  parti- 
cular manner  upon  a  nerve ;  but  when  causes  act  upon  the  brain 
generally,  and  palsy  follow,  we  are  obliged  to  assume  the  fact, 


PARALYSIS.  265 

and  give  up  the  attempt  at  explanation  ;  thus  the  action  of  moral 
causes  is  altogether  beyond  our  comprehension.  Considerations 
like  these,  has  led  Dr.  Powell*  to  the  opinion,  "  that  paralytic 
affections,  both  partial  and  general,  often  originate  in  a  peculiar 
condition  of  the  nerves  alone;  that  they  are  independent  of  any 
morbid  affection  of  the  blood-vessels  of  the  head ;  and  that  they 
are  produced  in  many  instances  by  cold,  and  in  some  by  sym- 
pathy with  particular  states  of  the  stomach,  or  other  distinct  local 
irritations."  Of  the  latter  kind,  Dr.  Physick  and  myself  attend- 
ed a  lady  who  had  a  palsy  of  the  arm  to  follow  not  a  very  severe 
indigestion,  and  of  which  she  entirely  recovered,  by  remedies 
altogether  addressed  to  the  stomach. 

890.  But  the  most  common  cause  of  partial  palsy  is  unques- 
tionably from  lead.  This  is  frequently  met  with  among  painters, 
plumbers,  workers  of  mines,  manufacturers  of  white  lead,  and 
all  such  as  are  obliged  to  work  in  this  metal  or  its  preparations. 
Local  applications  of  this  substance  has  produced  partial  palsy  ; 
we  knew  the  eyelid  paralyzed,  by  having  it  painted  with  white 
lead  and  lake,  to  hide  its  blackness,  from  a  blow.     Dr.  Cooket 
gives  the  following  account  of  the  symptoms  of  palsy  from  lead, 
as  taken  from  Dr.  Clutterbuck's  works  upon  this  subject. 

891.  "A  weakness  of  the  hands  is  the  first  thing  perceived ; 
the  patient  is  unable  to  grasp  any  thing  with  firmness.     This 
weakness  seldom  extends  itself  above  the  wrists,  but  he  is  tor- 
mented with  pains  in  the  shoulders  and  upper-arms,  resembling 
chronic  rheumatism.     The  weakness  soon  increases,  so  that  he 
loses  altogether  the  use  of  his  hands;  he  is  unable  to  support  the 
Kand  in  a  line  with  the  forearm,  and  he  can  with  difficulty  lift 
it  to  his  head.     The  fingers  are  incurvated,  and  he  is  unable  to 
extend  them  voluntarily;  not  that  they  are  rigidly  contracted, 
for  they  can  be  easily  straightened  by  any  extraneous  force ;  they 
remain  bent,  because  the  tonic  powers  of  the  flexors,  exceed 
somewhat  that  of  the  extensor  muscles.     No  diminution  of  the 
sensibility  of  the  skin  is  perceived  to  accompany  this  paralytic 
state  of  the  arm,  the  affection  seems  confined  to  the  muscles  alone; 
the  legs  are  seldom  affected  in  the  same  manner  as  the  arms  are 
found  to  be." 

Treatment. 

892.  Though  no  plan  of  treatment,  however  well  devised, 
will  be  always  certain  to  relieve  palsy,  nevertheless,  an  ill-di- 

*  Gregory's  Practice,  Vol.  II.  p.  51. 

\  Gregory's  Practice,  Vol.  II.  p.  52,  note  by  Dr.  Colhoun.  Dr.  C.  has  not 
designated  which  of  Dr.  Cooke's  works  he  has  taken  his  quotation  from;  it  Is 
not  at  p.  110  of  his  "Nervous  Diseases." 

34 


266  PARALYSIS. 

rected  one  is  sure  to  increase  its  evils.  There  is  no  disease  more 
empirically  treated  than  palsy;  the  vulgar,  and  but  too  many  of 
the  initiated,  seem  to  have  but  one  principle  to  govern  their 
therapeutical  views,  namely,  to  restore  power,  by  stimulants  ap- 
plied to  the  part  affected,  or  internally,  with  the  same  intention. 
It  is  therefore  not  to  surprise  us,  that  so  few  recover  from  this 
distressing  disease.  We  may  safely  say,  that  few  diseases  re- 
quire a  more  strict  attention  to  the  state  of  the  circulation,  or  a 
more  cautious  and  judicious  application  of  remedies,  than  the 
disease  in  question. 

893.  If  we  advert  to  the  causes  of  palsy,  or  trace  its  intimate 
relation  to  apoplexy,  we  shall  in  an  instant  perceive  the  impro- 
priety of  stimulants,  and  be  convinced  of  the  necessity  of  deple- 
tion, either  general  or  local  or  both,  as  the  exigencies  of  the  cir- 
culation may  require.  We  are  aware  that  much  prejudice  is  en- 
tertained against  "weakening  remedies"  in  palsy;  and  that  it 
would  be  much  easier  to  gain  the  consent  of  the  patient  or  his 
friends,  to  administer  the  most  violent  stimulants,  from  which 
death  might  quickly  follow,  than  to  draw  a  few  ounces  of  blood, 
that  might  probably  save  his  life. 

894.  Notwithstanding  the  decided  necessity  of  depletion  in 
many  instances  of  palsy,  it  is  not  always  so  obviously  indicated  as 
to  leave  no  doubt  upon  the  mind  of  its  propriety.  It  therefore  re- 
quires sometimes  much  discrimination  to  detect  the  necessity  of 
depletion;  and  no  inconsiderable  judgment  to  apportion  its  quan- 
tity; we  may  however  often  in  these  dubious  cases,  derive  advan- 
tage from  observing  the  effects  of  even  moderate  stimuli  upon  the 
nervous  and  sanguiferous  systems.     For  should  any  substance 
have  been  carelessly  or  injudiciously  exhibited,  under  an  impres- 
sion, or  otherwise,  of  its  necessity,  if  its  qualities  be  wrong,  that 
is,  over-stimulating  for  the  state  of  the  system,  though  feeble  in 
the  rank  of  this  class  of  medicines,  it  will  often  betray  its  in- 
compatibility, by  flushing  of  the  face,  general  uneasiness,  in- 
crease of  heat  and  thirst;  and  thus  discover  a  marked  phlogistic 
state  of  the  system. 

895.  The  pulse  will  however  generally  conduct  us  safely  in 
such  cases,  if  it  be  properly  consulted,  together  with  the  other 
phenomena,  that  the  system  presents  at  the  moment.     If  the 
pulse  be  full  and  slow,  or  unusually  quick  or  frequent;  if  there 
be  heat,  or  a  pricking  sensation  in  the  skin,  head-ache,  or  drowsi- 
ness, flushed  cheeks,  high-coloured  and  scanty  urine,  and  white 
tongue,  the  loss  of  a  few  ounces  of  blood  is  distinctly  indicated, 
either  by  the  use  of  the  lancet,  or  cups  or  leeches — if  the  pulse 
be  quick  or  frequent,  by  the  lancet;  if  sluggish,   by  cups  or 
leeches  to  the  back  of  the  neck  and  temples. 

896.  Purging  is  next  in  importance;  it  should  be  pretty  con- 


PARALYSIS.  267 

stantly  maintained,  especially  in  recent  cases,  to  break  in  upon, 
and  to  prevent  the  habit  of  determination  to  the  head,  and  this 
is  of  more  consequence  than  might  at  first  be  imagined;  for  it  is 
in  the  commencement  of  such  attacks  that  such  accumulations 
are  most  to  be  feared;  and  we  very  effectually  overcome  this 
disposition  from  fixing  on  the  brain,  by  diverting  the  flow  of 
blood  from  it  and  throwing  it  upon  the  intestines,  from  whence  it 
can  be  more  easily  discharged  by  cathartics,  than  from  the  brain, 
when  the  determination  sets  that  way.  In  young  subjects,  the 
neutral  salts  and  magnesia,  (par.  338,)  seem  to  answer  best;  in 
older  and  aged  people,  the  more  active  cathartics  should  be  used; 
as  jalap  and  cremor  tartar;  or  aloes,  rendered  active  by  combina- 
tion with  rhubarb,  as  directed  at  par.  293.  Calomel  is  oftentimes 
a  valuable  addition  to  the  other  purgatives ;  especially  where  the 
appearances  of  the  faeces  discover  a  redundancy  or  deficiency  of 
bile. 

897.  Blisters  to  the  neck,  and  these  repeated  occasionally, 
have  been  found  highly  serviceable,  after  due  depletion.     Other 
stimulating  remedies  have  been  advised,  such  as  electricity,  gal- 
vanism, stinging  with  nettles,  mustard,  from  none  of  which  have 
we  ever  seen  the  slightest  benefit  derived — for  a  momentary  sen-  . 
sation  excited  upon  the  skin,  can  never  change  the  pathological 
condition  of  the  brain,  which  gives  rise  to  the  disease.    A  strict 
attention  should  be  paid  during  the  whole  course  of  the  disease, 
to  the  diet  of  the  patient;  this  should  consist  of  the  lightest  and 
most  digestible  of  the  vegetable  substances — very  little  or  no  ani- 
mal food  should  be  indulged  in,  even  after  the  disease  has  become 
chronic ;  for  one  of  the  best  chances  of  recovery  is  afforded  by 
not  interfering,  by  stimulating  articles  of  diet,  with  the  recupe- 
rative powers  of  the  system.     Every  kind  of  liquor  must  be 
forbidden. 

898.  The  trials  made  in  this  country  of  the  nux  vomica,  do 
not  seem  to  justify  much  confidence  in  its  powers ;  of  the  rhus 
toxicodendron,  and  the  arnica  montana,  we  can  say  nothing. 

899.  The  cerebral  paraplegia  is  to  be  treated  upon  the  same 
general  principles ;  but  we  fear,  that  no  plan  so  far  can  be  relied 
upon.    Dr.  Baillie  however  thinks  he  has  derived  advantage  from 
cupping,  setons,  and  blisters  to  the  nape  of  the  neck,  and  free 
purging  by  the  more  active  cathartics,  as  the  extract  of  colocy nth, 
jalap,  and  the  neutral  salts.     He  thinks  he  has  seen  benefit  fol- 
low frictions  to  the  lower  limbs,  for  an  hour  at  a  time,  twice  a 
day;  from  electric  sparks,  tepid  bathing  in  fresh  and  salt  water. 

900.  We  are  informed  by  the  learned  and  useful  editor  of  the 
Medico-Chirur.  Rev.  for  April,  1831,  p.  477,  that  "  Dr.  Pritch- 
ard,  of  Bristol,  has  drawn  the  attention  of  the  profession  to  a 
mode  of  treating  old  and  obstinate  hemiplegia,  and  other  diseases 


268  EPILEPSY. 

of  the  head,  which  he  has  found  more  successful  than  any  other. 
He  properly  observes,  that  recent  cases  are  to  be  treated  by  anti- 
phlogistics,  and  local  depletion,  together  with  the  cautious  use  of 
mercury;  but  after  these  measures  have  been  pursued  for  a  cer- 
tain time,  depletory  remedies  can  no  longer  be  pursued — and 
counter  irritation,  with  a  drain  from  the  vicinity  of  the  disease, 
is  most  likely  to  be  beneficial.  For  this  purpose,  Dr.  P.  makes 
an  iniision  in  the  line  of  the  sagittal  suture,  or  posterior  to  that, 
and  fills  the  incision  with  peas,  which  are  to  be  renewed  and 
kept  discharging  for  a  considerable  length  of  time.  He  has  em- 
ployed this  method  in  many  other  affections  of  the  head  with 
advantage — more  especially  in  cases  of  stupor,  or  coma  occurring 
in  the  course  of  severe  typhoid  fevers." 

SECT.  IV. — EPILEPSY.* 

901.  This  afflicting  disease  has  triumphed  over  medical  skill 
from  the  time  of  Hippocrates  to  the  present  moment;  for  we 
dare  not  but  confess,  that  its  treatment  is  as  little  understood  at 
this  time,  as  it  was  in  his  day.     It  is  true  that  medical  records 
furnish  many  examples  purporting  to  be  "cured  epilepsy,"  yet 
there  is  too  much  reason  to  believe,  that  some  other  convulsive 
disease  has  been  mistaken  for  it,  or  else  they  have  been  cases  of 
"  sympathetic  epilepsy.'7. 

902.  Much  confusion  exists  in  the  history  and  symptoms  of 
this  disease;  so  much  so,  that  no  definition  has  hitherto  been 
given,  that  is  not  imperfect,  and  falls  short  of  what  it  should  be, 
or  else  is  evidently  made  to  embrace  too  much,  and  include  part 
of  the  symptoms  of  some  other  convulsive  affection.     Thus,  we 
find  certain  of  the  symptoms  of  hysteria  frequently  blended  with 
those  of  epilepsy;  and  what  is  still  more  embarrassing,  hysteria 
itself  we  have  every  right  to  believe  has  been  called  epilepsy; 
and  cures  of  this  terrible  disease  have  been  declared  to  have  been 
effected,  when  the  physician  has  only  combated  some  nervous 
affection.   Again,  the  convulsions  incident  to  childhood,  are  uni- 
formly included  by  authors,  in  epilepsy,  with  which  they  have 
perhaps  in  their  pathology  nothing  in  common;  though  they  have 
one  in  their  symptoms,  namely,  the  contortions  of  the  body. — 
but  convulsions  are  not  the  disease,  they  are  only  symptoms  of 
disease.     Had  the  convulsions  of  children  the  same  pathological 
or  anatomical  derangement  as  epilepsy  for  their  origin,  we  should 
have  an  hundred  epileptics  for  one — for  who  has  cured  epilepsy? 
Or  who  has  seen  the  convulsions  from  teething,  or  irritated 

*  "  Maladie  tellement  extraordinaire,  tellement  audessus  de  toute  intelli- 
gence, et  de  toute  explication  relativement  a  ses  causes  et  a  ses  symptomes, 
que  les  anciens  out  cru  qu'elle  dependait  du  courroux  des  dieux." — Esquirol. 


EPILEPSY.  269 

bowels,  perpetuated  through  life  ?  Yet  it  is  evident,  were  they 
pathologically  the  same  disease,  this  must  constantly  happen ; 
for  we  ask  again,  who  has  cured  epilepsy  ?  Or  who  does  not  ad- 
mit the  liability  of  children  to  convulsions? 

903.  This  disease  has  been  defined,  "  convulsion  with  stupor," 
by  Dr.  Cullen,  and  of  which  he  makes  three  species,  the  "cere- 
bral," the   "sympathetic,"  and  the  "occasional."     Esquirol 
gives  very  nearly  the  same  definition ;  namely,  "  a  convulsive 
disease  with  a  loss  of  consciousness."     It  is  evident  that  neither 
of  these  define  the  disease  with  the  accuracy  that  is  essential  to 
its  being  well  understood ;  for  agreeably  to  it,  hysteria,  syncope, 
the  convulsion  attending^great  losses  of  blood,  from  teething  in 
children,  those  which  terminate  hydrocephalus,  &c.  would  be 
cases  of  epilepsy.     It  is  much  better,  where  definition  cannot 
reach  the  essential  characters  of  a  disease,  to  give  a  general  his- 
tory of  the  symptoms  as  they  most  frequently  occur,  and  not  run 
the  risk-  of  obscurity  for  the  sake  of  brevity. 

Mode  of  Attack. 

904.  The  patient,  if  he  be  not  lying,  falls  suddenly,  and  be- 
comes instantly  convulsed — in  some  instances  every  muscle  of 
the  body  is  agitated ;  at  others,  they  are  neither  violently  nor 
universally  disturbed.    The  face  is  violently  and  frightfully  dis- 
torted— the  eyes  protrude  from  their  sockets,  sometimes  fixed, 
at  other  times  much  agitated ;  the  face  becomes  red,  then  purple, 
and  frequently  black.    The  lips  project,  and  often  swell  sudden- 
ly— the  mouth  is  sometimes  drawn  aside  towards  an  ear ;  froth 
is  convulsively  thrown  from  it;  sometimes  bloody  from  the 
wounded  tongue ;  inspiration  and  expiration  quickly  repeated, 
making  a  hissing  or  sibilating  noise.  The  jaws  powerfully  drawn 
together;  sometimes  including  the  tongue,  which  becomes  dread- 
fully wounded ;  the  grinding  of  the  teeth  both  loud,  and  power- 
ful ;  so  much  so  now  and  then  as  to  break  them.    At  times  they 
are  said  to  shriek  violently — we  do  not  believe  this  ever  happens 
in  the  idiopathic  or  genuine  epilepsy — this  resembles  hysteria, 
and  may  belong  as  a  symptom  to  the  hysterical  sympathetic  epi- 
lepsy.  The  hands  are  so  convulsively  shut,  and  the  fingers  made 
to  press  so  violently  against  the  palms,  that  they  become  some- 
times wounded  by  the  nails. 

905.  The  neck  or  throat  swell ;  the  external,  and  most  likely 
the  internal  vessels  of  the  head  and  neck,  are  so  much  distended 
as  apparently  to  threaten  bursting.  The  head  executes  move- 
ments in  almost  every  direction,  and  to  an  extent  sometimes, 
that  seems  to  threaten  the  spinal  marrow ;  or  it  is  rigidly  and 
immoveably  fixed,  until  the  paroxysm  is  about  to  subside.  In  a 


270  EPILEPSY. 

word,  as  above  stated,  every  muscle  is  violently  agitated,  or 
rigidly  fixed.  The  thumb  is  almost  always  included  in  the  grasp 
of  the  fingers,  and  pressed  strongly  against  the  palm  of  the  hand; 
the  patient  often  strikes  himself  violently,  if  his  arms  are  per- 
mitted to  be  free. 

906.  The  pulse^  is  small,  frequent,  or  extinct  in  the  beginning; 
but  as  the  fit  begins  to  relax  in  severity,  it  becomes  developed, 
hard,  unequal,  and  full.*     Urine  and  faeces  are  involuntarily 
passed ;  and  sometimes  in  the  male  of  proper  age,  the  semen  is 
discharged.     The  face  and  portions  of  the  body  are  inundated 
with  a  cold  sweat;  and  sometimes  blood , has  been  discharged 
from  the  eyes,  ears,  and  nose. 

907.  After  a  continuance  of  these  symptoms  for  a  longer  or 
shorter  time,  the  convulsive  motions  are  perceived  to  be  less 
violent;  the  face  loses  part  of  its  lividity;  changes  to  a  purple, 
and  presently  assumes  nearly  its  former  condition,  if  we  except 
swelling  of  the  lips,  &c.  The  respiration  becomes  less  laborious, 
the  inspirations  deeper,  and  the  expirations  longer ;  the  pulse  is 
frequent,  but  this  soon  diminishes  to  its  ordinary  standard.  The 
head  feels  giddy;  the  eyes  look  heavy,  but  stare  on  vacancy  for 
some  time;  the  limbs  relax  themselves,  and  seem  to  court  repose, 
in  which  they  are  oftentimes  indulged,  by  the  patient  falling  into 
a  sleep.    From  this  they  generally  wake  more  or  less  refreshed. 
At  other  times,  we  have  seen  an  habitual  epileptic,  get  up  and 
walk,  the  instant  the  fit  had  passed  over,  as  if  nothing  had  hap- 
pened.    Others,  especially  females,  we  have  known  on  the  con- 
trary, to  be  confined  to  their  beds  for  two  or  three  days  after  the 
paroxysm.     In  no  instance  that  we  have  seen,  does  the  patient 
retain  the  slightest  recollection  of  his  sufferings;  though  for  the 
most  part  they  complain  of  head-ache,  are  dull,  and  apparently 
have  a  sensation  of  shame ;  but  this  we  believe  is  peculiar  to  a 
combination  with  hysteria. 

908.  There  is  however  considerable  variety  in  the  force  as 
well  as  the  frequency  of  epileptic  paroxysms ;  while  some  are 
agitated  with  all  the  violence  just  detailed,  others  are  but  very 
slightly,  though  they  may  be  very  frequently  affected.  We  knew 
one  epilectic,  who  has  but  one  fit  each  spring ;  others  every  few 
months,  others  more  frequently,  while  others  have  them  repeat- 
ed upon  every,  and  very  slight  occasions. 

909.  The  access  of  an  epileptic  paroxysm  is  often  preceded 
by  a  very  peculiar  sensation,  called  "aura  epileptica."     It  is 
described  as  a  convulsive  movement;  pain;  a  sensation  of  cold, 
or  vapour;  it  is  felt  in  the  head,  the  face,  arms,  hands,  thighs, 

•  Dr.  Burnett  relates  a  case  of  epilepsy  in  a  gentleman  aged  forty-six,  which 
was  attended  by  a  pulse,  fourteen  beats  in  a  minute. — Med.  CMrur.  Trans. 
Vol.  XIII.  Part  I. 


EPILEPSY.  271 

legs,  toes,  chest,  stomach,  abdomen,  and  uterus.*  This  sensation 
or  affection,  is  propagated  along  the  members,  the  trunk,  the 
neck,  towards  the  head,  and  when  it  arrives  at  the  brain,  the 
patient  instantly  loses  all  consciousness;  and  either  partial  or 
general  convulsions  ensue ;  or  they  may  be  confined  to  the  mem- 
ber or  part  primarily  affected.  The  duration  of  the  "  fit"  is  very 
uncertain;  it  differs  in  different  individuals,  though  pretty  con- 
stantly the  same  in  the  same  person.  It  passes  sometimes  in  a 
few  seconds ;  it  may  continue  a  few  minutes,  or  it  may  last 
hours — the  common  period  is  however  from  five  to  fifteen  or 
twenty  minutes. 

910.  Epilepsy  has  sometimes  ceased  spontaneously,  upon  the 
return  of  the  catamenia,  or  of  a  suppressed  haemorrhagy;  or  of 
an  habitual  eruption,  when  it  has  been  symptomatic,  and  de- 
pending upon  the  absence  of  either  of  these  circumstances  ;  but 
we  believe  it  has  never  ended  in  this  manner  when  it  has  been 
idiopathie.  It  has  however  more  frequently  terminated  in  idiocy, 
or  mania.  And  even  if  it  does  not  do  this,  it  almost  always 
leaves  its  characters  upon  the  afflicted  patient,  if  it  has  been  of 

•  Mr.  Rankin  gives  a  case  of  epilepsy  caused  by  a  blow  upon  the  head, 
which  was  attended  by  the  aura.  In  this  case  it  commenced,  either  in  the  toe 
or  in  the  arm.  Edin.  Med.  and  Surg.  Journal,  Oct.  1830,  p.  318.  And  in  the 
Medico-Chirurgical  Review  for  Jan.  1827,  we  find  under  the  head  of  sympa- 
thetic epilepsy,  two  cases,  in  which  the  aura  was  more  remarkably  developed, 
than  any  we  have  ever  met  with.  As  these  cases,  together  with  the  observa- 
tions they  give  rise  to,  are  every  way  interesting,  we  shall  relate  them.  "  Sym- 
pathetic epilepsy. — Two  cases  of  this  kind  are  reported  in  the  Lancet  of  No- 
vember 18,  1826,  as  occurring  in  St.  Thomas's  Hospital.  The  first  was  a  boy 
who  had  been  affected  with  epilepsy  three  months,  having  generally  three  or 
four  fits  per  diem.  These  were  preceded  by  an  'aura  epileptica'  running  from 
the  toes  of  both  feet  up  along  the  front,  of  the  legs  and  thighs.  The  abdomen 
and  chest,  at  the  top  of  which  the  two  aura  met,  when  the  epileptic  seizure 
always  took  place.  The  progress  of  the  aura  required  about  a  minute,  and  *• 
produced  a  sensation  like  that  arising  from  the  crawling  of  an  insect.  Dr.  Elliot- 
son  directed  half  a  grain  of  the  cuprum  ammoniat.  thrice  a  day,  and  a  ligature 
to  be  applied  tightly  round  each  thigh  at  the  commencement  of  the  fit.  The 
ligatures  were  not  properly  managed  at  first,  and  the  fits  continued;  but  after- 
wards they  were  more  strictly  attended  to,  and  the  fits  ceased.  The  boy  was 
discharged,  but  again  received,  the  fits  having  returned.  The  ligatures  were 
now  trusted  to  entirely,  and  the  paroxysms  disappeared.  In  the  second  case, 
the  aura  epileptica  also  arose  from  the  feet,  and  ascended  to  the  neck,  where 
the  streams  met  and  the  paroxysm  occurred.  In  this  case  the  ligatures  were 
tried  but  totally  failed.  It  is  said  however  that  the  height  to  which  the  streams 
of  aura  epileptica  mounted,  was  gradually  lessened.  When  the  report  closed, 
the  fits  were  more  severe  than  at  first. 

The  aura  epileptica  is  one  of  the  most  puzzling  phenomena  of  this  disease. 
The  stream  does  not  seem  to  run  in  the  course  of  any  particular  nerve,  artery, 
or  muscle,  but  travels  over  all  parts  indiscriminately,  till  it  reaches  the  censo- 
rium.  The  ligature,  we  apprehend,  will  never  do  much  for  the  cure  of  epilepsy. 
It  is  too  mechanical  a  remedy.  It  is  veiy  unlikely  that  the  real  source  of  the 
irritation  is  in  the  place  where  the  aura  appears  to  commence.  The  plan  of 
stopping  it  by  ligature  has  long  ago  been  tried,  and  failed. 


272  EPILEPSY. 

long  standing — thus  the  features  become  enlarged,  the  lips 
thicken,  and  beauty  is  sometimes  transformed  into  deformity. 
The  size  of  the  legs  and  arms  are  thin  and  out  of  proportion  to 
other  parts  of  the  body,  &c. 

Diagnosis. 

911.  There  are  several  points  of  resemblance  between  epi- 
lepsy and  several  other  affections;  some  of  which  are  so  marked 
that  we  have  reason  to  believe,  that  one  has  been  sometimes  mis- 
taken for  the  other.  Thus  in  epilepsy,  the  patient  falls  suddenly 
from  his  feet — the  same  happens  in  sudden  accessions  of  syncope 
and  apoplexy;  the  same  we  have  known  to  take  place  at  the  com- 
mencement of  an  hysterical  paroxysm.     Foaming  at  the  mouth 
is  a,  constant  symptom  almost  in  epilepsy;  yet  it  is  observed 
sometimes  in  apoplexy,  asphyxia,  and  in  hysteria.    Involuntary 
discharges  sometimes  take  place  in  epilepsy,  so  also  do  they  oc- 
casionally happen  in  apoplexy  certainly,  and  perhaps  in  other 
convulsive  affections. 

912.  Yet  epilepsy  differs  from  apoplexy,  in  not  having  ster- 
torous breathing  ;  in  there  being  little  or  no  convulsion  ;  in  the 
pulse  being  nearly  or  quite  natural;  in  the  paroxysm  being  vastly 
more  prolonged,  and  terminating  for  the  most  part  in  two  or 
three  days.     Epilepsy  can  scarcely  be  confounded  with  syn- 
cope, though  the  initial  symptoms  sometimes  of  both  resemble 
each  other  very  much.     We  knew  a  lady  that  would  faint  with- 
out any  apparent  cause  sometimes;  and  at  others,  from  the 
slightest — we  have  seen  her  suddenly  fall  upon  the  floor,  be 
slightly  convulsed  for  a  moment,  and  then  display  all  the  genuine 
symptoms  of  syncope — that  is,  she  would  not  breathe,  the  pulse 
would  be  perhaps  extinct,  death-like  paleness,  and  the  muscles 
of  the  whole  body  in  a  state  of  relaxation.     It  has  often  how- 
ever been  confounded  with  hysteria,  and  hysteria  with  it — hys- 
teria almost  always  has  premonitory  symptoms,  such  as  palpita- 
tion of  the  heart;  globus  hystericus;  cold  feet;  disposition  to  cry 
or  laugh;  and  the  paroxysm  is  never  so  sudden.     The  character 
of  the  convulsions  are  different;  they  are  more  confined  to  one 
side  in  epilepsy,  or  in  a  single  member.     The  throat  swells  in 
hysteria,  as  does  the  abdomen — wind,  or  borborygmi  are  almost 
constant ;  but  above  all,  there  is  a  recollection  of  what  has  hap- 
pened. 

Remote  Causes. 

913.  The  remote  causes  of  epilepsy,  are  said  to  be  very  nu- 
merous; among  the  most  certain  perhaps  is  hereditary  predispo- 


EPILEPSY.  273 

sition.  This  seems  to  be  very  generally  acknowledged,  but  the 
fact  is  not  so  generally  known,  or  admitted,  that  other  affections 
of  the  cerebral  organs,  appear  to  be  as  certain  in  their  powers 
of  transmission,  as  epilepsy  itself — thus  mania  and  idiotism,  seem 
to  perpetuate  the  same  predisposition,  as  epilepsy  does.  Does 
this  consist  in  that  peculiarity  of  the  nervous  system,  which  Dr. 
Cullen  terms  mobility  ? 

914.  It  has  been  insisted  on  by  some,  that  there  is  something 
in  the  general  organization  of  the  nervous  system,  that  disposes 
to  epilepsy;  for  say  they,  the  female  is  more  obnoxious  to  it  than 
the  male.  It  is  said  also,  that  the  character  of  the  female  consti- 
tution, bears  a  strong  resemblance  to  the  peculiarities  of  infancy, 
and  hence  its  liability  to  epilepsy ;  because,  say  they,  children 
from  a  variety  of  causes,  are  more  obnoxious  to  it  than  the  more 
aged.     But  before  the  liability  of  the  female  constitution  to  epi- 
lepsy be  predicated  upon  a  resemblance  to  the  peculiarities  of 
infancy,  two  things  should  first  be  proved — 1st,  that  this  ana- 
logy exists;  and  2d,  that  the  female  are  more  subject  to  epilepsy, 
than  the  same  number  of  the  male  at  puberty,  or  adult  age. 

915.  Now,  as  regards  the  first,  there  is  no  analogy  between 
the  two  states  of  the  system  at  the  time  designated ;  and  if  this 
were  the  case,  it  would  prove  the  contrary  of  what  they  desire; 
since  we  must  insist,  that  children  under  seven,  or  even  ten,  are 
very  rarely  afflicted  with  epilepsy ;  and  when  they  are,  it  is  al- 
most sure  to  be  traced  to  hereditary  taint,  or  to  some  other  very 
evident  cause.     That  they  are  liable,  very  liable,  to  convulsions, 
we  have  admitted,  (par.  903,)  but  we  must  repeat,  that  "con- 
vulsion" is  but  the  sign  of  disease ;  and  however  liable  young 
children  may  be  to  irritations  that  cause  convulsions,  we  utterly 
deny  that  they  are  to  epilepsy.     First,  because  the  convulsions 
of  children  are  almost,  or  perhaps  always,  preceded  by  signs  that 
discover  this  affection  about  to  take  place,  as  is  well  known  to 
every  experienced  physician  and  observing  nurse.     Second,  be- 
cause the  phenomena  are  unlike;  in  the  convulsion  of  children, 
the  eyes,  the  mouth,  and  the  arms  are  principally  affected.  Third, 
when  the  paroxysm  is  over,  the  child  lies  for  the  most  part  in  a 
state  of  stupor;  occasionally  even  for  a  long  time.  Fourth,  that  the 
convulsions  of  children  last  as  a  general  rule,  very  much  longer, 
and  are  repeated  very  much  more  frequently,  than  in  epilepsy. 
Fifth,  that  those  children  who  may  have  recovered  from  the 
convulsions  of  infancy,  seldom  or  never  have  them  repeated  in 
after-life — our  experience  does  not  furnish  us  with  an  instance, 
though  we  would  not  attempt  to  deny  but  such  a  consequence 
may  have  followed.     Therefore,  all  that  relates  to  the  causes  of 
convulsions  in  children,  as  teething,  and  affections  of  the  stomach 

35 


274  EPILEPSY. 

and  bowels,  should  be  stricken  from  the  list  of  remote  causes  of 
epilepsy. 

916.  2d.     We  should  however  be  obliged  to  admit,  that  the 
female  is  more  liable  to  epilepsy  than  the  male,  if  the  accounts 
of  their  respective  numbers  in  the  Salpetriere,  and  the  Bicetre, 
were  correct;  or  rather,  if  the  cases  reported,  purporting  to  be 
cases  of  epilepsy,  be  really  and  truly  cases  of  genuine  epilepsy, 
though  it  is  altogether  at  variance  with  our  own  observations. 
We  cannot  pretend  to  fix  the  proportion,  that  we  believe  exists 
between  the  sexes,  who  may  be  afflicted  with  epilepsy,  but  at  a 
rough  guess,  we  should  think  there  were  three  males  to  a  female. 
Our  present  knowledge  of  such  cases,  would  exceed  this  num- 
ber, but  from  this  we  do  not  pretend  to  establish  a  rule,  as 
proportion  must  occasionally  fluctuate.      In   the  hospitals  just 
named,  the  imputed   proportion,  is  considerably  greater  with 
females.     In  this  however  there  may  be  great  error,  from  con- 
founding all  convulsive  diseases  under  one  title. 

917.  Errors  in  diet,  too  great  exposure  to  the  direct  rays  of 
a  hot  sun ;  the  intemperate  use  of  strong  liquors;  irritating  sub- 
stances taken  into  the  stomach,  are  said  to  have  produced  epilep- 
sy.    The  removing  of  eruptions  of  long  standing  from  the  skin; 
healing  up  of  ulcers;  the  suppression  of  customary  evacuations; 
and  the  sudden  check  of  perspiration,  have  sometimes  produced 
epilepsy  in  soldiers,  agreeably  to  military  surgeons;  but  these  can 
only  be  exciting  causes. 

918.  Esquirol  even  confounds  the  occasional  convulsions  of 
eruptive  diseases  with  epilepsy  ;  for  among  the  causes  producing 
symptomatic  epilepsy,  he  enumerates  the  small-pox,  the  measles, 
the  scarlet  fever  when  they  are  about  to  show  themselves  upon 
the  skin.     Labour,  anger,  mortification,  &c.  have  also  agreeably 
to  him  produced  epilepsy.     That  labour  has  had  convulsions  to 
accompany  it  sometimes,  we  well  know — but  these  convulsions 
are  not  epileptic  convulsions,  strictly  so  called ;  first,  because 
they  always  have  premonitory  signs  a  longer  or  shorter  time — 
we  have  known  instances  in  which  head-ache,  giddiness,  and 
imperfect  vision  has  preceded  the  convulsions  many  days,  or 
hours;  second,  we  have  every  reason  to  believe,  that  under  the 
circumstances  just  mentioned,  convulsions  have  been  frequently 
prevented  by  the  loss  of  blood;  but  genuine  epilepsy  is  not  pre- 
vented by  this  means,  however  carefully  and  regularly  attended 
to ;  third,  such  patients  as  have  escaped  with  life,  from  puerperal 
convulsions,  have  never  had  a  recurrence  of  them, so  far  as  we  have 
observed;  not  necessarily  even  during  their  subsequent  labours; 
fourth,  in  an  epileptic  female,  whom  we  attended  many  years, 
we  never  observed  the  slightest  injury  to  arise  from  the  occur- 


EPILEPSY.  275 

rence  of  a  fit,  during  any  period  of  pregnancy,  in  the  height  of 
labour,  or  immediately  after — now,  all  who  are  at  all  versed  in  ob- 
stetrics know,  that  the  convulsions  of  labour,  unless  purely  hys- 
terical, are  replete  with  danger.* 

919.  And  as  regards  the  convulsions  which  precede  eruptive 
diseases,  every  body  knows  that  in  general  they  are  free  from 
danger,  however  alarming  they  may  be  in  appearance ;  and  these, 
like  all  those  already  mentioned  as  belonging  to  childhood,  are 
never  repeated  in  after-life. 

920.  With  respect  to  the  agency  of  moral  causes,  we  have 
little  to  say  from  our  own  observation,  never  having  seen  an 
unequivocal  instance  of  it;  yet  we  can  readily  believe,  that  they 
may  be  among  the  most  certain,  and  most  common  of  the  ex- 
citing causes — for  they  can  be  no  other.   On  this  point, post  hoc, 
ergo,  propter  hoc,  has  been  tenaciously  and  faithfully  observed; 
yet  it  may  not  always  be  true.     Esquirol  cites  a  number  of  in- 
stances in  support  of  the  agency  of  these  causes. 

921.  When  epilepsy  has  once  taken  possession  of  the  sys- 
tem, slight  causes,  whether  moral  or  physical,  will  sometimes 
produce  a  return  of  the  paroxysm,  provided  the  time  for  a  return 
be  at  hand — but  for  the  most  part,  they  observe  periodical  move- 
ments; and  when  the  period  has  arrived,  the  ''fit"  takes  place 
without  the  necessity  of  any  exciting  cause;  as  happens  in  inter- 
mittent fever.     Our  own  experience,  therefore,  will  not  permit 
us  to  agree  with  Esquirol,  that  "  the  application  of  the  same  kind 
of  exciting  cause  that  produced  the  original  paroxysm,  though  of 
inferior  force,  will  produce  a  renewal  of  an  epileptic  paroxysm;" 
unless  indeed,  the  period  at  which  it  is  wont  to  return,  be  at 
hand.     When  causes  operate  in  the  manner  declared  by  him,  it 
is  most  probable  that  hysteria  has  much  to  do  with  the  paroxysm. 
The  lady  whose  case  we  have  just  mentioned,  has  often  been  tried 
by  moral  causes  of  apparently  sufficient  force  to  produce  a  parox- 
ysm of  hysteria  in  constitutions  liable  to  this  affection;  yet  with 
her  we  have  never  known  them  bring  on  her  "  malady,"  unless 
it  may  have  been  at  the  period  of  its  return — we  have  witnessed 
her  grief  at  the  loss  of  a  child ;  and  we  observed  her  agony  at  the 
sudden  death  of  a  husband  to  whom  she  was  much  devoted;  but 
in  neither  instance  did  her  epilepsy  obtrude  itself.     Now,  these 
"  causes,"  as  is  well  known,  would  have  excited  hysteria,  and 
in  some  instances  even  for  the  first  time,  yet  this  lady  had  neither 
epilepsy  nor  hysteria,  to  accompany  the  grief  occasioned  by  her 
bereavements. 

922.  The  remote  causes  of  idiopathic  epilepsy,  must  neces- 
sarily operate  some  change  either  in  the  brain,  or  its  dependen- 

*  See  System  of  Midwifery,  by  the  author,  Art.  "  Puerperal  Convulsions." 


276  EPILEPSY. 

cies;  but  in  what  these  changes  consist,  it  is  difficult,  if  not  impos- 
sible at  this  time  to  prove.  Many  of  the  causes  enumerated  as 
capable  of  producing  epilepsy,  can  only  cause  this  disease  by 
acting  upon  this  condition ;  or  in  other  words,  when  an  epileptic 
paroxysm  is  called  forth,  the  brain  or  its  appendages  must  be  in 
a  particular  condition,  to  be  operated  upon  by  these  exciting 
causes ;  but  that  it  is  not  essential  to  epilepsy  to  have  these  causes 
constantly  present,  to  produce  a  "fit,"  since  we  see  this  take  place 
without  their  agency.  It  would  seem  then,  that  the  patho- 
logical condition  of  the  brain  or  its  appendages,  may  differ  in 
degree ;  one,  requiring  the  operation  of  some  evident  exciting 
cause ;  while  the  other  subjects  the  system  to  periodical  returns 
of  convulsive  movements  without  such  agencies. 

923.  If  this  be  true,  plethora,  irritations  of  the  digestive  or- 
gans, and  all  the  moral  agencies,  can  be  but  exciting,  and  not  pre- 
disposing causes  to  epilepsy.    The  same  may  be  said  of  the  sup- 
pression of  customary  evacuations,  or  affections  of  the  skin,  &c. 
for  we  do  not  believe  that  either  of  them  can  produce  that  pa- 
thological, or  anatomical  condition  in  the  brain  and  nervous  sys- 
tem that  is  essential  to  true  epilepsy — we  admit  they  may  give 
rise  to  convulsions,  but  we  have  already  sufficiently  insisted, 
(par.  902,)  that  convulsions'is  only  a  sj^mptom  of  disease,  and 
is  not  the  disease  itself. 

924.  So  little  positive  is  known  of  the  pathology  of  epilepsy, 
that  no  two  authorities  scarcely  admit  the  same  proximate  cause. 
In  most  instances,  dissection  has  only  revealed  certain  departures 
from    healthy  structure,  and  which  may  perhaps    be    claimed 
rather  as  the  consequences  of  epilepsy,  than  its  cause.    We  shall 
however  relate  in  a  very  brief  manner,  the  various  observations 
upon  this  point,  which  have  been  collected  with  much  industry 
by  Esquirol,  in  his  essay  upon  this  subject,  in  the  Diet,  des  Sci- 
ences Med.  Art.  Epilepsie. 

925.  "  Leduc  has  noticed  the  heads  of  epileptics  are  larger, 
the  cranial  bones  thicker,  and  the  sutures  often  effaced." 

926.  "  Bont6  has  seen  the  head  deformed ;  and  Morgagni  has 
several  times  seen  the  same  thing." 

927.  "  Bonte  once  found  the  occipital  bones  nine  lines  thick; 
and  Zacchius  found  the  inner  table  of  the  skull  destroyed  by 
caries. " 

928.  "  Bontius  saw  a  child  of  six  weeks  old  thrown  into  an 
epileptic  fit  by  the  pressure  of  its  cap,  (beguin ;)  but  which  was 
cured  by  its  removal."     The  same  relates,  "that  a  young  man 
became  epileptic  from  a  stroke  upon  the  head,  in  his  infancy." 

929.  "  Bony  concretions  are  frequently  found  upon  the  dura 
mater,  and  upon  the  falciform  process — these   are   sometimes 
round,  sometimes  drawn  out  and  pointed." 


EPILEPSY.  277 

930.  Esquirol  says,  "  in  dissecting  an  epileptic,  aged  twenty- 
three  years,  who  died  in  the  fit,  I  found  adhering  to  the  inter- 
nal face  of  the  dura  mater  an  osseous  tumour  of  an  oval  form, 
eight  lines  in  breadth,  and  depressing  the  superior  convolutions 
of  the  brain." 

931.  "  The  vessels  of  the  meninges  have  been  found  dilat- 
ed, engorged,  varicose,  containing  fibrous  concretions,  and  even 
bone." 

932.  Morgagni  says,   "  in  a  woman  who  had  been  epileptic 
for  two  years,  he  found  the  lower  part  of  the  anterior  third  of 
the  left  lobe  of  the  brain  very  soft;  in  eight  epileptics,  the  brain 
was  found  soft,  by  Greding.    Morgagni,  Greding,  Meckel,  and 
Boerhaave,  found  the  brain  hard,  even  callous." 

933.  The  capacity  of  the  ventricles,  the  presence  of  more 
or  less  water,  serous  cysts  developed  in  the  substance  of  the  plex- 
us choroides,  offer  varieties  without  end,  and  "  without  furnish- 
ing any  positive  data." 

934.  "  Scirrhous,  adipose,  and  osseous  tumours  have  develop- 
ed themselves  in  the  ventricles  and  the  substance  of  the  brain. 
Bauhin  and  Borrichius  have  seen  abscesses  in  the  substance  of 
the  brain. " 

935.  "  The  pineal  gland  has  been  found  to  contain  osseous 
concretions,  very  often,  yet  no  conclusions  can  be  drawn  from 
the  circumstance.    Baillie  and  Soemmering  have  found  this  gland 
preternaturally  firm ;  Greding  has  met  with  it  soft  in  twenty- 
five  epileptics,  and  in  twenty  it  was  surrounded  by  serum." 

936.  Wenzel  has  made  many  observations  upon  the  glandula 
pituitaria,  which  he  found  in  almost  every  condition  it  was  sus- 
ceptible of,  without  any  particular  alteration  of  the  brain  itself; 
he  found  many  also  in  the  pineal  gland,  "  without  these  lesions 
enabling  us  to  conclude  whether  they  were  the  cause  or  the  effect 
of  epilepsy."     Many  other  anomalies    might  be  produced  to 
prove,  how  little  light  has  been  thrown  upon  this  subject  by  pa- 
thological research;  and  how  unsafe  it  would  be  to  draw  any 
other  inference,  than,  that  so  far,  we  know  nothing  of  the  pa- 
thology of  epilepsy. 

937.  We  shall  conclude  this  brief  history  of  cerebral  lesions, 
with  the  reflections  of  Esquirol  upon  this   point.     He   asks, 
"  what  conclusions  can  be  drawn  from  all  these  researches,  par- 
ticularly those  of  Bonet,  Morgagni,  Baillie,  Greding,  Meckel, 
and  Wenzel  ?  None,  unless  it  is  that  the  same  lesions  have  been 
found  in  subjects  who  were  not  epileptic,  as  has  been  proved  by 
Wepfer,  and  Lorry.     Let  us  then  honestly  confess,  that  patho- 
logical anatomy  has  not  up  to  this  moment  thrown  the  least 
light  upon  the  immediate  seat  of  epilepsy.     But  let  us  not  be 
discouraged;  nature  will  not  always  resist  our  efforts.     What 


378  KPILEPSY. 

shall  we  say  to  the  numberless  reveries  that  have  been  promul- 
gated upon  the  proximate  cause  of  this  disease?  The  ancients 
attributed  it  to  the  influence  of  the  moon,  and  to  the  vengeance 
of  heaven,  or  to  enchantment.  Have  the  moderns  explained  the 
subject  by  their  own  systems?  Where  shall  we  find  the  matter 
that  irritates  the  nerves?  Who  has  seen  the  animal  spirits;  who 
has  measured  the  power  of  their  elasticity?  Some  have  attributed 
it  to  the  power  of  an  archaeus;  to  a  tumultuous  and  confused  move- 
ment of  the  vital  principal  of  the  rational  soul.  Hoffmann  attri- 
butes it  to  a  derangement  in  the  course  of  the  humours,  which  pre- 
vents the  distribution  of  their  spirituous  parts.  Some  others  de- 
clare it  to  be  owing  to  a  contraction  of  the  dura  mater,  the  en- 
velopes of  the  brain,  and  the  nerves,  &c.  &c." 

938.  Esquirol  proceeds  to  an  analytical  view  of  the  causes 
which  produce  the  symptoms  that  characterize,  and  the  organs 
involved  in  epilepsy;  but  without  its  tending  to  any  practically 
good  purpose;  for  of  the  mode  of  curing  this  disease  upon  firm  and 
rational  principles,  we  are  entirely  ignorant:  that  there  has  been 
occasionally  a  cure  of  idiopathic  epilepsy,  we  are  disposed  to 
hope;  that  there  has  been  instances  of  success  in  the  symptomatic, 
we  have  every  reason  to  believe,  though  we  fear  not  to  the  ex- 
tent that  medical  record  declares.     For  when  these  cases  are 
carefully  examined,  too  much  reason  is  found  for  the  belief,  that 
hysteria  under  some  peculiar  form  has  been  mistaken  for  it ; 
and  if  appeal  be  made  to  the  convulsions  of  childhood,  arising 
from  teething,  &c.  as  instances  of  the  cure  of  epilepsy,  we  utterly 
deny  the  sameness  or  identity  of  the  diseases,  and  for  the  reasons 
already  declared,  (par.  902.) 

Prognostic, 

939.  This  disease,  though  eventually  fatal,  is  rarely  so  in  its 
commencement;  and  when  it  proves  so,  it  is/  perhaps  most  fre- 
quently by  the  production  of  other  diseases,  or  extreme  exhaus- 
tion.    The  cases  most  decidedly  intractable,  are  those  which 
arise  from  hereditary  predisposition.     When  it  is  sympathetic 
it  is  occasionally  a  curable  disease ;  and  this  is  also  said  of  the 
idiopathic  form.     Those  who  may  be  attacked  in  early  life  with 
epilepsy  remain  incurable,  unless  a  favourable  change  take  place 
at  puberty.     Those  attacked  between  the  fourth  and  tenth  year, 
may  be  cured  by  proper  treatment ;  and  if  seized  near  the  time 
of  puberty,  are  cured  when  that  period  arrives ;  if  after  puberty, 
they  are  sometimes  relieved.     Marriage  cures  no  other  than  ge- 
nital epilepsy ;  it  augments  the  other  species.  Women  incur  great 
risk  from  epilepsy  during  pregnancy.    When  the  "  fits"  become 
more  frequent  and  increase  in  intensity,  we  have  reason  to  fear 


EPILEPSY.  279 

death.  Death  does  not  take  place  during  the  paroxysm,  but 
after  it,  from  exhaustion.  Epilepsy  combined  with  mental  de- 
rangement is  never  cured. 

940.  It  will  be  seen  from  this  short  detail  of  the  prognostics 
in  epilepsy,  that  much  confusion  prevails;  or  rather  a  constant 
blending  of  affections  of  a  convulsive  kind,  with  the  true  or  idio- 
pathic  epilepsy.     Thus  the  cases  which  are  said  to  be  relieved 
by  puberty,  cannot  be  idiopathic  epilepsy ;  since  it  is  relieved 
by  a  functional  process  of  the  uterus  in  females,  and  of  the  testi- 
cles in  the  male,  neither  of  which  can  change  the  state  of  dispo- 
sition of  the  brain  and  nervous  system  so  entirely,  as  to  prevent 
the  action  of  other  exciting  causes.  The  same  may  be  said  of  the 
effects  of  marriage ;  that  is,  it  cures  an  affection  of  the  uterus, 
called  epilepsy,  (which  is  nothing  but  a  modification  of  hysteria,) 
while  it  augments  a  genuine  epilepsy.  We  have  already  remark- 
ed upon  the  convulsions  of  pregnancy  or  labour,  (par.  918.) 

Treatment. 

941.  What  plan  of  treatment  has  ever  succeeded  in  curing 
epilepsy?  We  regret  to  answer,  none!    Has  epilepsy  ever  been 
cured?  We  fear  we  shall  but  declare  a  most  unwelcome  truism, 
when  we  also  answer  this  in  the  negative.  We  mean  not  to  deny 
that  patients  supposed  to  have  had  this  disease,  have  been  cured; 
and  that  others  who  were  perhaps  truly  epileptic,  have  got  well; 
but  in  the  true  meaning  of  the  word,  we  fear  it  has  never  been 
cured.     These  assertions  are  founded  upon  the  many  hundred 
failures,  to  a  single  cure ;  and  the  same  remedy  not  succeeding 
twice  in  the  same  hands,  or  perhaps  ever  again  in  the  hands  of 
any  body.  For  it  is  a  melancholy  truth,  that  a  cure  for  epilepsy, 
is  no  sooner  announced,  than  it  never  again  proves  successful, 
however  often,  or  faithfully  it  may  be  tried. 

942.  Does  not  the  multiplication  of  quack,  or  specific  reme- 
dies, emphatically  declare,  the  impotency  of  every  regular  mode 
of  treatment?    Where  now  is  the  lauded  power  of  the  nitrate  of 
silver,*  of  arsenic,  of  steel,  of  zinc,  of  musk,  of  opium,  the  load- 

*  Though  this  remedy  has  never  succeeded  in  our  hands,  it  seems  but  fair  to 
put  the  reader  in  possession  of  the  experience  of  others  who  have  employed 
it — we  therefore  select  the  following-  account,  from  the  Medico-Chirurgical 
Review  for  January,  1827,  p.  241. 

"  Epilepsy  cured  by  nitrate  of  silver." — "  Dr.  Balardini  has  added  one  to  the 
many  instances  on  record  of  the  efficacy  of  this  remedy  in  epileptic  fits.  The 
patient  was  a  young  woman,  aged  twenty-one  years,  who  from  infancy,  was 
subject  to  this  complaint.  It  had  now  become  very  severe,  very  frequent,  and 
the  paroxysms  often  followed  by  temporary  alienation  of  the  mind.  Various 
remedies  had  been  used  in  vain,  when  Dr.  B.  gave  the  argentum  nitratum  a 
fair  trial.  He  commenced  with  two  grains  a  day,  and  gradually  increased  the 


280  EPILEPSY. 

stone,  the  bark,  the  mercurials,  and  an  hundred  others  of  equal 
celebrity,  but  of  less  power?  They  have  one  and  all  passed  into 
an  oblivion  from  which  they  will  perhaps  never  be  recalled. 

943.  Where  convulsions,  call  them  epileptic  if  you  please, 
depend  upon  an  anormal  condition  of  some  other  organ  than  the 
brain,  by  treating  such  affections  successfully,  we  may  arrest  the 
sympathetic  affection;  but  in  these  instances,  we  only  cure  an 
affection  of  some  organ  in  which  the  disposition  to  epilepsy  did 
not  exist,  and  altogether  different  from  epilepsy;  but  we  do  not 
cure  epilepsy  strictly  speaking ;  in  this  case,  the  convulsion  is 
prevented,  because  the  disease  on  which  it  depended  has  been 
relieved ;  and  a  proof  that  we  did  not  cure  epilepsy  directly,  is, 
that  our  remedies  were  not  addressed  to  its  seat,  nor  from  their 
nature  were  they  calculated  to  directly  relieve  epilepsy.     It  is 
agreed  that  nothing  can  be  done  in  the  "fit,"  except  perhaps  to 
abridge  its  duration — this  is  done  sometimes  by  blood-letting; 
by  cold  water  dashed  in  the  face;  by  removing  all  confining  liga- 
tures from  the  throat  and  waist;  by  elevating  the  head  of  the  pa- 
tient, and  giving  him  fresh  air.     Dr.  Reid*  however  appears  to 
have  more  confidence  in  certain  mechanical  means  in  interrupt- 
ing a  paroxysm  of  epilepsy  than  we  have  allowed  ourselves  to 
indulge  in ;  and  if  the  plan  proposed  by  him,  is  really  followed 
by  the  effects  he  states,  it  merits  consideration.     His  treatment 
consists  of  one  of  two  methods.     1st.   "  Forcibly  extending  the 
hands  and  opening  the  fingers  of  the  patient."     The  2d,  and 
agreeably  to  the  author  of  the  paper,  the  more  powerful  is  to  be 
accomplished  "  by  pressing  the  closed  hand  of  an  assistant  forci- 
bly on  the  soft  part  of  the  abdomen,  towards  the  spine,  while 
the  patient  is  firmly  supported  on  the  back,  with  the  head  and 
shoulders  raised.7' 

944.  In  hysteria,  a  condition  every  way  analogous,  we  are 
certain  we  have  seen  mischief  follow  the  first  plan. 

945.  Dr.  Gregory  lays  down  the  following  concise  directions 
for  the  management  of  the  patient  in  the  intervals.     1.  To  re- 
dose.  The  medicine  was  continued  three  months,  and  never  produced  any  bad 
effects.    Occasionally  it  acted  slightly  on  the  bowels.    The  patient  was  cured. 

"We  are  inclined  to  think  that  this  medicine  will  be  more  used  than  here- 
tofore. If  epilepsy  be  dependent  on  organic  disease  of  the  brain,  we  do  not 
see  that  the  nitrate  of  silver  can  do  any  harm,  but  probably  good,  if  due  atten- 
tion be  paid  to  local  evacuations  from  the  head,  and  counter  irritation.  If,  as 
is  very  often  the  case,  the  disease  be  connected  with  irritation  in  the  primae 
viz,  there  is  no  other  medicine  more  likely  to  remove  this  irritation,  or  at  least 
to  remove  the  morbid  sensibility  of  the  gastric  and  intestine  nerves,  than  the 
nitrate  of  silver. 

"Dr.  Darwell  also  gives  the  history  of  an  interesting  case  of  epilepsy  which 
was  permanently  relieved  by  this  remedy,  in  doses  of  five  grains  three  times 
a  day." 

*  Dublin  Transactions,  Vol.  IV. 


EPILEPSY.  281 

move  all  sources  of  irritation.  2.  To  moderate  the  afflux  of  blood 
upon  the  brain.  3.  "The  last,  though  not  the  least,"  to  alter 
that  morbid  condition  of  the  nervous  system,  on  which  convul- 
sion depends. 

946.  Let  us  see  how  these  indications  are  directed  to  be  ful- 
filled ;  and  notice  with  what  propriety  the  first  can  be  consider- 
ed as  applying  to  the  treatment  for  which  the  indication  is  laid 
down.  In  "  epilepsies  of  infants  and  children  much  may  be  done 
by  free  scarifications  of  the  gums ;  by  the  administration  of  an 
emetic;  by  occasional  smart  doses  of  purgative  medicines;  by  the 
more  liberal  use  of  mild  aperients  and  absorbents;  and  by  strict 
attention  to  the  diet  and  regimen."  We  have  already  said,  (par. 
915,)  that  convulsions  from  teething,  and  intestinal  irritation  in 
children,  are  not  the  convulsions  of  epilepsy;  we  shall  therefore 
rest  our  objections  to  the  views  of  Dr.    Gregory,  upon  what 
was  then  said.     If  we  are  correct  in  our  views,  the  fulfilment 
of  this  first  indication  cannot  be  looked  upon  as  referring  to 
epilepsy. 

947.  And  when  it  is  proposed  in  epilepsy  depending  upon  the 
state  of  the  uterus,  can  the  indication  under  consideration  be  ful- 
filled, by  "the  warm  bath,  or  semicupium;  stimulating  ene- 
mata;  relaxing  medicines,  as  the  antimonial  diaphoretics,  and 
the  different  kinds  of  emmenagogues;  regular  exercise;  occa- 
sional purgatives;  issues  or  setons."  Will  these  remedies  remove 
all  the  sources  of  irritation  ? 

948.  "  The  second  principle  in  the  treatment  of  epilepsy  is 
the  obviating  general  plethora" — this  is  to  be  done  by  blood- 
letting, by  diet,  by  exercise;  abstinence  from  liquors,  and  bath- 
ing the  head  and  neck  with  cold  water;  cupping,  blisters,  and 
the  steady  use  of  purgatives,  &c. 

949.  The  third  is  to  be  fulfilled  by  "the  exhibition  of  narco- 
tics, as  camphor,  opium,  hyosciamus,  and  stramonium/'     Now 
we  would  ask  for  information,  whether  a  genuine  epilepsy  was 
ever  benefited  by  the  observance  of  these  "principles?" 

950.  Will  it  be  fair  to  predicate  the  present  incurable  nature 
of  epilepsy  upon  our  own  want  of  success  in  this  disease  ?    Cer- 
tainly it  will;  for  in  our  attempts  to  cure  this  disease,  we  have 
constantly  followed  the  rules  that  have  been  laid  down,  and  ex- 
hibited the  remedies  prescribed  and  extolled  by  others — we  had 
no  opinions  at  one  time  of  our  own  upon  this  subject;  for  when 
we  attempted  to  treat  it,  it  was  by  implicitly  following  the  rules 
of  others.     Our  failures  have  been  constant;  and  we  are  free  to 
confess  that  we  have  never  succeeded  in  curing  epilepsy,  pro- 
perly so  called,  in  our  lives,  though  we  have  in  one  instance  suc- 
ceeded in  relieving  a  lad  who  had  periodical  "fits,"  that  follow- 
ed on  intermittent  fever,  by  the  use  of  Fowler's  solution ;  and 

36 


282  CHOREA    SANCTI   VITI. 

at  present  we  have  very  much  moderated  the  same  kind  of  pa- 
roxysms in  a  man,  who  has  had  an  intermittent  of  long  standing, 
and  by  the  same  remedy — yet  we  dare  not  say  we  have  ever 
cured  epilepsy,  especially  as  we  do  not  believe  that  either  was  a 
case  of  this  kind. 

951.  From  all  this  we  must  conclude;  1,  that  much  confusion 
exists  upon  the  subject  of  this  disease;  other  affections  being  con- 
stantly called  epilepsy ;  2,  that  the  convulsion  from  teething,  &c. 
in  children ;  and  hysteria  in  women,  are  not  under  any  modifi- 
cation, epilepsy ;  3,  that  the  instances  of  relief,  purporting  to  be 
cures  of  epilepsy,  have  been,  (with  very  few,  if  any  exceptions,) 
some  other  affections ;  4,  that  to  the  present  moment,  we  are  not 
more  enlightened  as  regards  the  pathology  of  epilepsy,  than  they 
were  in  the  time  of  Hippocrates  ;  5,  and  that  at  this  moment,  it 
must  be  looked  upon  as  an  incurable  disease. 

952.  We  shall  conclude  our  observations  on  epilepsy  by  quot- 
ing the  following  observations: — "  In  all  cases  of  epilepsy,  it  is 
of  great  consequence  to  keep  the  nervous  system  in  a  quiet  state, 
and  especially  those  organs  with  which  the  brain  more  imme- 
diately sympathizes.     Although  the  cause,  as  structural  disease 
in  the  brain  cannot  be  removed,  it  may  be  rendered  dormant, 
by  tranquillizing  the  nervous  system.     With  this  view,  all  the 
mineral  and   vegetable  anodynes  and  derivative  irritants  have 
been  recommended,  and  each  has  had  its  warm  advocate;  espe- 
cially the  prussic  acid,  colchicum,  hemlock,  henbane,    deadly 
nightshade,  arsenic,  quinine,   sulphate  of  quinine,  aconite,  &c. 
By  rendering  the  system  unsusceptible  of  epileptic  derangement 
for  many  months,  by  the  regular,  judicious  use  of  an  anodyne, 
the  local  cause  may  undergo  such  a  change  as  to  remain  dormant 
for  life." — Rees  on  Costiveness, p.  238. 

SECT.  V. — CHOREA  SANCTI  VITI,  OR  ST.  VITUS'  DANCE. 

953.  The  disease  about  to  be  described,  acquired  its  name 
in  Germany,  where  it  was  first  noticed,  in  consequence  of  per- 
sons who  suspected  themselves  to  be  afflicted  with  this  curious 
convulsion,  performing  an  annual  pilgrimage  to  the  Chapel  of 
St.  Vitus,  where  they  danced  night  and  day  with  the  view  of 
curing  it;  since  that  time,  the  Greek  word  choreia,  or  chorea, 
which  signifies  "  dance"  has  been  substituted. 

954.  This  affection   was  first  well  described  by  Sydenham ; 
and  since  more  extensively  and  accurately  by  Dr.  James  Hamil- 
ton of  Edinburgh.     Sydenham  describes  it  as,  "  a  kind  of  con- 
vulsion, which  principally  attacks  children  of  both  sexes,  from 
ten  to  fourteen  years  of  age.     It  first  shows  itself  by  a  lameness 
or  rather  unsteadiness  of  one  of  the  legs,  which  the  patient  draws 


CHOREA    SANCTI    VITI.  283 

after  him,  like  an  idiot,  and  afterwards  affects  the  hand  on  the 
same  side,  which  being  brought  to  the  breast,  or  any  other  part, 
can  by  no  means  be  held  in  the  same  posture  for  a  moment,  but 
is  distorted  or  snatched  away  by  a  kind  of  convulsion  into  a  dif- 
ferent posture  or  place,  notwithstanding  all  possible  efforts  to 
the  contrary.  If  a  glass  of  liquor  be  placed  in  the  hand  to  drink, 
before  the  patient  can  get  it  into  his  mouth,  he  uses  a  thousand 
odd  gestures;  for  not  being  able  to  carry  it  in  a  straight  line 
thereto,  because  his  hand  is  drawn  different  ways  by  the  con- 
vulsion ;  as  soon  as  it  has  reached  the  lips,  he  throws  it  suddenly 
into  his  mouth,  and  drinks  it  very  hastily,  as  if  he  only  meant 
to  divert  the  spectators." 

955.  To  this  description,  Dr.   Hamilton  adds  a  number  of 
circumstances  every  way  important  to  the  history  of  the  symp- 
toms, that  discover  the  commencement,  and  mark  the  progress 
of  this  oftentimes  very  afflicting  disease.     He  thinks  those  who 
naturally  possess  feebleness  of  stamina,  or  who  may  have  suffer- 
ed in  their  constitution  from  disease,  are  most  obnoxious  to 
chorea.     The  period  of  its  attack  is  from  eight  to  fourteen  ;  but 
Dr.  H.  saw  two  females  attacked  with  it,  who  had  arrived  at 
from  sixteen  to  eighteen  years.     To  this  may  be  added,  that  we 
once  saw  it  in  a  married  woman  of  twenty-five,  and  this  during 
pregnancy,  and  from  which  she  was  relieved  by  bleeding,  purg- 
ing, and  the  sulphate  of  zinc. 

956.  Dr.  H.  says  "  the  approaches  of  chorea  are  slow."  This 
however,  is  not  always  the  case;  we  once  saw  it  in  a  little  girl 
of  seven  years,  suddenly  induced,  in  consequence  of  a  previous 
intermittent  of  four  paroxysms.     It  is  generally  however,  pre- 
ceded by  symptoms  which  denote  a  loss  of  power  in  the  digestive 
organs;  at  the  same  time,  some  involuntary  motion  of  different 
muscles  may  be  observed,  particularly  of  the  face.  The  convul- 
sive motions  are  not  confined  to  any  particular  muscles ;  they 
may  exist  in  those  of  the  extremities,  of  the  lower  jaw,  the  head, 
or  the  trunk. 

957.  These  motions  differ  in  degree  or  force ;  they  are  how- 
ever constant,  except  during  sleep ;  deglutition  and  articulation 
become  impaired ;  the  eyes  become  heavy ;  the  countenance  pale 
and  vacant,  even  to  the  appearance  of  fatuity ;  which,  if  the  dis- 
ease persist,  will  really  take  place.     Fever  rarely  exists;  but  the 
body  wastes,  and  the  digestion  becomes  impaired,  as  the  com- 
mon consequences  of  chorea. 

958.  There  are  two  species  of  chorea;  the  idiopathic  and 
sympathetic ;  some  have  attempted  greater  divisions,  without  ad- 
vantage to  the  mode  of  cure. 


284  CHOREA    SANCTI    VITI. 


Idiopathic  Chorea. 

959.  By  this  term  is  to  be  understood,  such  instances  of  this 
disease,  as  are  neither  the  symptom,  nor  the  effect  of  any  pre- 
ceding disease.     This  may  occur  during  any  part  of  the  period 
designated  above.     This  species  is  generally  preceded  by  feel- 
ings of  uneasiness,  paleness,  head-ache,  pains  in  the  limbs,  loss 
of  appetite,  &c. 

Predisposing  Causes. 

960.  We  have  remarked  above,  (par.  955,)  that  children  and 
others  of  debilitated  habits  were  more  obnoxious  to  this  complaint 
than  those  of  confirmed  health,  and  when  the  change  of  the  con- 
stitution from  infancy  to  puberty,  is  about  establishing  itself, 
the  nervous  system  is  very  apt  to  be  more  disposed  than  usual  to 
be  acted  upon;  especially  if  the  parents  of  such  patients  have 
been  disposed   to   nervous  affections.     Indeed,   it   is  evident, 
there  is  some  circumstance  connected  with  the  condition  of  the 
nervous  system  at  this  period  of  life,  that  disposes  to,  or  invites 
an  attack  of  chorea;  as  it  is  rarely  seen  in  adult  age,  and  never  in 
old  age. 

Exciting  Causes. 

961.  Whatever  is  sufficient  to  agitate  the  nervous  system 
powerfully  is  sufficient,  in  patients  disposed  to  this  disease,  to 
produce  chorea;  hence  frights,   anger,   distress  of  mind,  and 
even,  according  to  Geoffrey,  inflammations  or  frettings  of  the 
genital  organs,  will  induce  an  attack. 

Prognostic. 

962.  This  disease,  when  uncomplicated,  is  never  we  believe 
dangerous;  it  is  therefore  only  necessary  to  attempt  to  ascertain 
its  duration.     This  will  of  course  be  very  much  influenced,  by 
the  age,  the  nature  or  strength  of  the  constitution,  and  the  force 
and  continuance  of  the  exciting  and  predisposing  causes.     If  the 
patient  be  very  feeble,  and  the  attack  severe,  the  risk  of  its  con- 
tinuance will  be  increased,  and  on  the  contrary ;  but  this  is  not 
constant.    We  have  seen  two  instances  of  very  obstinate  chorea, 
in  patients  who  were  very  far  from  being  weak;  and  we  have 
seen  it  removed  very  speedily  in  two  others,  where  the  patients 
were  very  much  debilitated.     If  it  attack  before  puberty,  it  is 
sometimes  immediately  relieved  by  the  eruption  of  the  menses. 
We  once  visited  a  patient  violently  affected  with  chorea,  and  on 


CHOREA    SANCTI   VITI.  286 

which  the  slightest  impression  could  not  be  made,  though  she 
was  several  times  bled,  liberally  purged,  and  rigorously  dieted, 
for  three  months;  her  pulse  maintaining  its  force  throughout 
the  whole  period,  when  she  was  suddenly  relieved  by  the  ap- 
pearance of  the  catamenia,  though  the  patient  was  under  thirteen 
years  of  age. 

Treatment. 

963.  This  disease  has  almost  constantly  been  classed  among 
the  nervous  affections;  hence  the  place  given  it  by  both  Cullen 
and  Pinel ;  while  Sauvage  ranked  it  with  the  spasmi.  These  no- 
sological  locations,  had  a  most  unfortunate  influence  upon  the 
treatment  of  this  disease,  for  it  naturally  led  to  the  exhibition  of 
tonics  and  antispasmodics;  hence  the  indiscriminate  and  almost 
universal  use  of  bark,  steel,  camphor,  opium,  oil  of  amber,  musk, 
zinc,  all  the  vegetable  bitters,  and  electricity,  until  Dr.  Hamil- 
ton happily  revived,  and  successfully  extended,  the  practice  of 
Sydenham  in  this  disease. 

964.  It  occurred  to  him,  "  that  the  debility  and  spasmodic  mo- 
tions, hitherto  so  much  considered,  might  not  be  the  leading 
symptoms  of  the  disease,  but  might  depend  upon  previous  and 
increasing  derangement  of  health,  as  indicated  by  irregular  appe- 
tite, and  constipated  bowels." 

965.  "  Under  this  impression  with  regard  to  the  erroneous 
opinions  which  I  had  heretofore  entertained  concerning  the  na- 
ture of  the  disease,  and  the  consequent  improper  treatment  which 
I  had  employed  for  the  cure  of  it,  I  resolved  to  alter  my  mode 
of  treatment,  in  order  that  I  might  fulfil  those  indications  which 
the  new,  and  as  I  flattered  myself,  the  more  correct  view  of  the 
disease  had  suggested." 

966.  Under  these  impressions,  he  began  the  cure  of  chorea 
by  purgatives;  he  commenced  with  the  weaker  cathartics,  but 
he  soon  found  the  stronger  were  necessary,  as  almost  constant- 
ly indurated  faeces  were  discharged  by  them.     He  could  not 
however  determine  by  any  sign,  the  cases  in  which  these  exist- 
ed in  the  greatest  quantity;  he  nevertheless  came  to  the  conclu- 
sion, that  the  duration  of  the  disease,  and  the  reduced  state  of 
the  patient,  give  rise  to  the  greatest  quantities. 

967.  In  the  commencement  of  the  complaint,  where  the  in- 
testines retain  their  sensibility,  and  "  before  the  faecal  accumu- 
lations   become  great,  gentle  purgatives,  repeated  as  occasion 
may  require,  will  readily  effect  a  cure,  or  rather  will  prevent  the 
full  formation  of  the  disease.  In  the  confirmed  stage,  more  pow- 
erful purgatives  become  necessary;  they  "  must  be  given  in  suc- 
cessive doses,  in  such  a  manner  that  the  latter  doses  may  sup- 
port the  effects  of  the  former,  till  the  movement  and  expulsion 


286  CHOREA    SANCTI   VITI. 

of  the  accumulated  matter  are  effected,  when  symptoms  of  re- 
turning health  appear.  Whoever  undertakes  the  cure  of  chorea 
by  purgative  medicines,  must  be  decided  and  firm  to  his  purpose." 

968.  The  recovery  from  chorea  is  slow  and  gradual — but  ap- 
petite is  renewed,  strength  accumulates,  and  the  patient  is  re- 
stored after  a  time  to  a  usual  state  of  health.     But  it  is  neces- 
sary after  these  favourable  changes  take  place,  that  the  bowels 
be  occasionally  moved  by  purgative  medicine. 

969.  Tonics  may  now  be  employed;  the  vegetable  bitters, 
and  chalybeates  are  the  best  for  the  purposes  of  the  system.  The 
regimen  should  be  light  and  nourishing,  and  exercise  in  the  open 
air  should  come  in  aid  of  the  tonics. 

970.  Geoffroy  recommends  for  female  patients,  bleeding  in 
the  foot,  or  the  application  of  leeches  to  the  vulva,  where  the 
disease  appears  to  depend  upon  the  suppression  of  the  menses, 
or  where  this  discharge  is  due,  but  does  not  appear.     In  addi- 
tion to  the  use  of  purgatives,  we  can  with  great  confidence  re- 
commend the  use  of  the  la«cet,  whenever  there  is  head-ache, 
febrile  irritation,  and  an  active  pulse.     During  the  whole  of  the 
time  in  which  the  depleting  plan  is  carrying  on,  the  diet  should 
be  exclusively  vegetable,  unless  some  circumstance  of  the  sto- 
mach forbids  its  use — their  drink  should  be  water.     "  A  series 
of  tartar  emetic  plasters  along  the  spine,  together  with  purga- 
tives, combined  with  the  nitrate  of  silver,  is  recommended  as  an 
effectual  plan  of  treatment.  A  grain  of  the  nitrate  of  silver,  with 
five  grains  of  the  compound  extract  of  colocynth,  and  two  of  the 
pilula  hydrargyri,  was  given  for  several  weeks,  by  which  the  al- 
vine  excretions  were  brought  to  a  natural  condition  from  the 
most  vitiated  state  we  ever  beheld.     The  power  of  walking  in- 
creased as  the  secretions  and  excretions  improved."     Medico- 
Chirurgical  Review,  Oct.  1829, p.  483.  The  tartar  emetic  oint- 
ment applied  to  the  scalp  until  a  plentiful  eruption  is  produced, 
is  also  much  extolled.  Ib.     Dupuytren  treats  this  complaint  by 
cold  bath  and  cold  affusions.     The  patient  is  to  be  held  in  the 
bath  for  a  moment,  and  the  immersion  is  to  be  repeated  five  or 
six  times  in  the  course  of  fifteen  or  twenty  minutes.     The  im- 
mersion produces  violent  spasms  of  the  muscles  and  particularly 
those  of  the  chest.     The  sensation  felt  by  the  patient  is  highly 
disagreeable,  being  that  of  immediate  suffocation,  but  this  feeling 
is  very  evanescent;  the  patient  is  to  take  exercise  for  half  an 
hour  or  an  hour  after  the  bath,  and  this  should   be  of  an  active 
kind.     The  symptoms  gradually  abate,  and  the  disease  cured  in 
the  course  of  fifteen  or  twenty  days,  that  may  have  existed  for 
years  previously.     Simple  affusion  of  cold  water  on  the  head 
and  body  repeated  six  or  seven  times  in  succession,  produces 
the  same  good  effect.     When   women   are  the  subjects  of  this 
disease,  affusion  is  preferred  to  the  bath. 


TETANUS.  287 

971.  We  should  not  however  in  the  treatment  of  chorea  con- 
fine our  views  too  exclusively  to  the  state  of  the  intestinal  canal, 
as  there  is  strong  reason  to  believe  that  a   morbid  condition  of 
the  spinal  marrow  or  even  the  brain  itself,  may  be  the  original 
cause  of  this  disease ;  for  it  is  now  a  well  ascertained  fact,  that 
the  large  nervous  masses,  or  the  nervous  ganglia,  may  be  in  a 
pathological  condition,  while  the  phenomena  to  which  this  con- 
dition gives  rise,  may  exhibit  themselves  in  portions  of  the  body 
remote  from  their  seat.     Hence,  the  success  attendant  upon  the 
plan  just  named  above,  of  the  application  of  the  tartrite  of  anti- 
mony to  the  spine.     It  would  therefore  accord  best  with  careful 
practice,  to  examine  cautiously  the  state  of  the  spine  in  all  pa- 
tients labouring  under  chorea.     This  should  be  done,  by  having 
the  spine  exposed,  and  then  slowly  and  firmly  making  pressure 
upon  it,  from  the  first  cervical  vertebra,  to  the  last  of  the  dorsal, 
at  least.     If  during  this  examination  the  patient  discover  or  de- 
clare the  existence  of  tenderness  in  any  particular  portion  of  the 
spinal  column,  remedies  should  be  first  addressed  to  the  tender 
portion  of  the  vertebrae — leeching  should  be  premised;  or  even 
repeated  at  the  interval  of  a  few  days.     This  may  be  followed 
by  blistering  or  by  the  tartar  emetic  ointment.* 

SECT.  VI.— TETANUS. 

972.  There  are  few  diseases  more  deeply  distressing  or  more 
certainly  fatal,  than  tetanus.     This  disease  is  divided  by  nosolo- 
gical  writers,  into  several  species ;  as  opisthotonos,  emprostho- 
tonos,t  trismus,  &c.     Upon  this  division  of  tetanus,  Dr.  Cullen 

*  Dr.  Jesse  Young  (a_)  has  lately  directed  the  attention  of  the  medical  pub- 
lic, to  the  use  of  the  black  snakeroot,  (cirnicifuga  racemosa,)  for  the  curd  of 
chorea,  and  in  which  he  appears  to  have  great  confidence.  He  has  given  four 
or  five  cases  as  illustrative  of  its  efficacy,  which  appear  entitled  to  confidence. 
He  orders  a  tea:spoonful  of  the  powdered  root  three  times  a  day  in  almost  any 
vehicle.  If  it  offend  the  stomach  when  taken  before  breakfast  or  other  meals, 
its  exhibition  may  be  delayed  until  an  hour  after  each  meal.  He  appears  in 
every  case  he  has  related  to  have  continued  its  use,  with  but  occasional  inter- 
ruptions, until  the  symptoms  have  disappeared. 

f  It  has  been  doubted  by  some,  whether  this  form  of  tetanus  can  possibly 
take  place,  because  the  muscles  on  the  anterior  portion  of  the  body  are  much 
fewer  in  number  as  well  as  much  weaker  in  power  than  those  that  antagonize 
them  on  the  posterior  part  of  the  body.  But  we  have  the  authority  of  Larrey 
and  others  for  that  species  of  tetanus,  called  emprosthotonos.  Larrey  says, 
"in  wounds  that  cause  traumatic  tetanus,  if  it  be  the  nerves  of  the  anterior  re- 
gion of  the  body  that  have  been  wounded,  I  have  remarked,  that  emprostho- 
tonos is  the  consequence}  while  on  the  contrary,  opisthotonos  takes  place, 
when  the  nerves  of  the  posterior  portion  is  wounded,  and  if  the  wounding 
cause  has  traversed  a  part  so  as  to  affect  equally  both  planes  of  nerves,  tetanus 
becomes  completely  established,  and  throws  the  body  into  a  straight  line." — 
Clinique  Chirurgicale,  torn.  I.  p.  85. 

C a}  Amer.  Jour,  of  the  Med.  Sciences,  for  Feb.  1832. 


288  TETANUS. 

very  justly  remarks,  all  these  several  terms,  denote  but  different 
degrees  of  one  and  the  same  disease.  In  this,  we  believe  all 
practical  writers  agree,  as  it  appears  every  way  certain  that  the 
remedies  that  may  conquer  one,  will  overcome  either  or  all  the 
other  varieties. 

973.  This  disease  consists  of  tonic  convulsions,  or  permanent 
rigidity  of  a  part,  or  of  the  whole  of  the  voluntary  muscles  of 
the  body.     It  sometimes  invades  suddenly;  but  at  other  times, 
it  slowly  arrives  at  its  height.     When  its  approach  is  slow,  a  ri- 
gidity of  the  muscles  of  the  neck  is  perceived,  attended  by  pain 
when  the  head  is  moved ;  a  sense  of  uneasiness  is  also  felt  about 
the  root  of  the  tongue,  some  difficulty  in  swallowing,  and  even- 
tually this  faculty  is  entirely  interrupted.     A  distressing  pain  is 
now  felt  at  the  lower  extremity  of  the  sternum,  which  darts 
backwards  to  the  spine.   At  this  period,  the  head  is  pulled  back- 
wards, and  the  muscles  employed  in  this  action,  are  thrown  into 
spasm,  while  those  serving  to  elevate  the  lower  jaw  become 
rigid,  and  so  closely  press  the  teeth  upon  each  other,  as  to  leave 
no  space  between  them.     When  the  spasm  is  confined  to  the 
parts  just  named,  the  disease  is  called  trismus,  or  locked  jaw. 

974.  The  pain  situated  at  the  extremity  of  the  sternum,  now 
recurs  frequently  and  most  painfully  ;  and  is  sure  to  be  accom- 
panied by  spasms  in  the  muscles  on  the  back  of  the  neck.    This 
painful  affection  is  not  always  limited  to  the  parts  just  named — 
it  frequently  travels  down  the  muscles  connected  with  the  spine, 
and  bends  the  body  backwards ;  and  thus  constitutes  the  species 
called  opisthotonos.     The  lower  extremities  become  rigidly  ex- 
tended, as  both  the  extensors  and  flexors,  are  equally  beset  by 
spasm;  while  the  muscles  of  the  abdomen  are  violently  retracted 
through  the  whole  course  of  the  disease,  and  in  point  of  hard- 
ness resembles  a  plane  of  board. 

975.  "  At  length,"  says  Dr.  Cullen,  "the  flexors  of  the  head 
and  trunk  become  so  strongly  affected  as  to  balance  the  exten- 
sors, and  to  keep  the  head  and  trunk  straight,  and  rigidly  ex- 
tended, incapable  of  being  moved  any  way ;  and  it  is  to  this 
state  the  term  tetanus  has  been  strictly  applied.     At  the  same 
time,  the  arms  little  affected  before,  are  now  rigidly  extended  ; 
the  whole  of  the  muscles  belonging  to  them  being  affected  with 
spasms,  except  those  that  move  the  fingers,  which  often  to  the 
last,  retain  some  mobility.     The  tongue  also  long  retains  its  mo- 
bility ;  at  length  it  also  becomes  affected  with  spasm,  which,  at- 
tacking certain  of  its  muscles  only,  often  thrusts  it  violently  out 
between  the  teeth." 

976.  "  At  the  height  of  the  disease,  every  organ  of  voluntary 
motion  seems  to  be  affected ;  and  amongst  the  rest,  the  muscles 
of  the  face.     The  forehead  is  drawn  up  into  furrows,  the  eyes, 


TETANUS.  289 

sometimes  distorted, are  commonly  rigid  and  immoveable  in  their 
sockets ;  the  nose  is  drawn  up,  and  the  cheeks  are  drawn  back- 
wards towards  the  ears,  so  that  the  whole  countenance  expresses 
the  most  violent  grinning.  Under  these  universal  spasms  a 
violent  convulsion  commonly  comes  on,  and  puts  an  end  to  life." 
Cullen.  When  death  ensues,  it  is  generally  from  an  engorged 
state  of  the  brain,  or  apoplexy. 

977.  "  These  spasms  are  every  where  attended  with  most  vio^ 
lent  pain.     The  utmost  violence  of  spasm  is,  however,  not  con- 
stant; but  after  subsisting  for  a  minute  or  two,  the  muscles  ad- 
mit of  some  remission  of  contraction,  though  of  no  such  relaxa- 
tion as  can  allow  the  action  of  their  antagonists.    The  remission 
of  contraction  gives  some  remission  of  pain  ;  but  neither  is  of 
long  duration."     Cullen. 

978.  These  painful  contractions  are  however  easily  reexcited, 
by  any  attempt  at  change  of  posture,  or  of  motion ;  even  speak^ 
ing,  or  an  effort  made  to  swallow,  will  renew  them. 

979.  Tetanus  is  rarely  attended  by  fever-^-in  this  most  autho^ 
rities  agree  ;*  and  little  or  nothing  is  to  be  learned  from  the 
pulse.      "From  the  state  of  the  pulse,"  says  Dr.  Hennen,  "I 
have  derived  no  clue  to  either  the  proper  treatment,  or  the  pro- 
bable event."    Military  Surgery,  p.  250.     While  Dr.  Caldwell 
says,  "  we  do  not  recollect  ever  to  have  seen  a  case  of  tetanus, 
in  which  the  patient  was  entirely  exempt  from  febrile  action. 
At  the  commencement  of  the  disease,  the  pulse  is  oftentimes  full 
and  frequent,  tense  and  strong.  Blood  drawn  at  this  time  throws 
up  a  covering  of  coagulating  lymph."     Note  to  Cullen's  First 
Lines.     But  all  this  does  not  prove  fever  to  be  essential  to  the 
disease.     Dr.  Cullen  says,  "  although  fever  be  not  a  constant  at- 
tendant of  this  disease,  especially,  when  arising  from  a  lesion  of 
the  nerves;  yet  in  those  cases  proceeding  from  cold,  a  fever  has 
sometimes  supervened,  and  is  said  to  be  attended  with  inflamma- 
tory symptoms."     As  regards  our  own  experience  in  tetanus,  it 
has  been  confined  altogether  to  cases  of  the  traumatic  kind,  and 
produced  by  punctures,  or  slight  incisions;  in  no  one  instance  of 
these,  was  there  any  decided  evidence  of  fever;  it  is  true,  the 
pulse  was  accelerated,  and  even  tense  and  active ;  but  these  ap- 
peared to  be  rather  the  effect  of  pain  and  muscular  exertion,  than 
evidence  of  febrile  excitement.     For  as  a  general  rule  we  have 

*  The  evidence  of  Fournier-Pescay,  is  in  direct  opposition  to  this  general 
statement;  he  says,  "  the  skin  is  dry  and  burning;  the  pulse  is  accelerated, 
hard,  full,  and  sometimes  convulsive."  "  Those  who  have  declared  that  teta- 
nus is  not  generally  attended  by  fever  have  not  studied  the  disease;  and  the 
assertion  of  Hillary,  that  when  tetanus  is  produced  by  a  wound,  or  an  openu 
tion,  it  is  unattended  by  fever,  is  unworthy  of  belief."  Diet,  des  Scien.  Med.* 
art.  Tetanos. 

37 


290  TETANUS. 

found  the  skin  below  the  natural  standard  of  heat;  and  rather 
shrunken  or  collapsed,  in  its  appearance.  We  think  however 
with  Dr.  Cullen,  that  it  may  accompany  certain  of  the  cases, 
arising  from  cold;*  and  we  add,  when  the  disease  has  been  pro- 
duced by  extensive  injuries.  Dr.  Gullen  is  unwilling  to  admit 
the  "  inflammatory  crust, "  as  he  says,  that  the  blood  drawn  in 
this  disease  never  exhibits  it.  But  if  this  were  even  a  common 
occurrence,  we  now  know,  that  this  appearance  does  not  always 
depend  upon  inflammation.  In  the  case  however  as  just  men- 
tioned, from  Dr.  Perry,  the  blood  was  sizey  at  first. 

980.  The  mental   functions  are  rarely  disturbed   in  tetanus; 
unless  perhaps  it  be  when  the  patient  is  absolutely  in  articulo 
mortis — for  we  have  seen  them  preserve  their  senses  to  the  last 
moment  of  life.     Indeed  few  of  the  natural  functions  are  much 
impaired  ;  we  have  known  a  keen  relish  for  food  continue  to  the 
last,  and  the  digestive  powers  remain  apparently   unimpaired. 
The  bowels  it  is  true,  are  obstinately  costive;  but  whether  this 
be  one  of  the  characters  of  the  disease,  or  only  the  effect  of  the 
general  mode  of  treatment,  is  perhaps  doubtful ;  we  are  however 
disposed  to  believe  it  belongs  essentially  to  tetanus  ;  since  nearly 
all  the  muscular  structures  are  deeply  implicated   in  this  affec- 
tion ;  it  is  therefore  probable  that  the  peristaltic  motion  of  the 
bowels  is  diminished,  as  well  as  the  muscular  powers  of  the 
bladder,  as  the  urine  is  sometimes  suppressed,  or  is  voided  with 
difficulty. 

Causes. 

981.  The  remote  causes  of  tetanus  are  much  better  ascertained, 
than  the  mode  of  cure.     The  remote  causes  may  be  divided  into 
general,  and  local ;  and  these  causes,  have  given  rise  to  the  di- 
vision of  idiopathic,  and  symptomatic,  or  traumatic  tetanus.t 

*  In  one  of  the  cases  related  by  Dr.  Perry,  (American  Jour,  of  the  Med. 
Sciences,  for  Nov.  1831,)  the  disease  was  brought  on  by  scalding,  the  pulse 
was  100  on  the  second  day  after  the  accident,  and  the  tongue  white  and  moist, 
and  the  first  cup  of  blood  was  sizey;  these  symptoms  may  perhaps  with  much 
propriety  be  said  to  be  febrile,  as  it  is  perhaps  very  probable,  that  fever  would 
have  attended  the  wound  alone;  and  this  may  have  been  the  source  of  the  fe- 
brile state  of  the  system.  So  in  other  instances  of  tetanus  from  extensive  le- 
sion, fever  may  be  a  concomitant  from  this  cause;  but  is  not  an  essential  con- 
dition to  this  disease.  This  is  rendered  the  more  probable,  as  by  far  the 
greater  number  of  the  cases  of  tetanus  that  we  witness,  arise  from  slight  and 
apparently  insignificant,  wounds;  wounds,  which  as  mere  lesions,  would  not 
have  excited  the  vascular  system  to  inordinate  action. 

f  Fournier  objects  to  the  term  traumatic  tetanus;  he  says,  that,  "tetanus, 
from  whatever  cause,  or  whatever  may  be  the  previous  pathological  condition 
of  the  patient,  is  always  identical  in  its  nature,  and  consequently  we  cannot 
divide  it  into  species." 


TETANUS.  291 

The  former,  or  the  idiopathic  tetanus  is  occasioned  by  exposure 
of  the  body,  to  sudden  changes  in  atmospheric  temperature ;  and 
especially  where  the  range  of  the  thermometer  is  high,  during 
the  day,  and  considerably  diminished  during  the  night* — hence 
this  affection  is  much  more  frequent  in  hot,  and  intertropical 
climates;  and  in  these,  in  particular  locations ;  as  for  instance, 
near  the  seacoast,  or  on  highly  elevated  situations.  The  long 
continued  operation  of  heat,  disposes  in  a  remarkable  manner  to 
the  production  of  tetanus,  by  exalting  the  sensibility  of  the  ner- 
vous system,  and  the  irritability  of  the  muscular.  It  also  aug- 
ments cutaneous  transpiration  in  a  remarkable  degree;  and  thus 
rendering  the  surface  of  the  body  more  susceptibleto  the  influence 
of  changes  in  atmospheric  temperature.  But  if  we  are  to  credit 
Schmucker,  "tetanus,  (symptomatic,)  occurred  very  frequently 
in  the  Prussian  army  from  slight  wounds  in  the  mountainous 
districts  of  Bohemia,  where  in  summer  the  days  are  extremely 
warm,  and  the  nights  uncomfortably  cold."  (Eberle.) 

982.  All  classes  of  people  are  obnoxious  to  tetanus  in  tropical 
countries ;  it  spares  no  age,  nor  respects  either  sex,  though  the 
male  is  said  to  be  more  liable  to  it  than  the  female.  This  may 
be  perhaps  satisfactorily  accounted  for,  from  the  man  being  more 
liable  to  both  the  remote  and  exciting  causes  of  this  disease,  t  A 
disordered  state  of  the  alimentary  canal,  has  also  been  said  to 
give  rise  to  this  affection.  Carrying  a  dead  child  in  utero,  has 
been  charged  by  Dr.  Eberle  with  producing  tetanus — both  of 
these  conditions  however,  we  are  of  opinion  have  been  assigned 
as  causes  of  this  disease,  post  hoc,  ergo  prop ter  hoc.  Especially 
the  latter,  as  children  dying  in  utero  is  very  common,  yet  we 
believe  this  is  the  only  instance  upon  record,  where  tetanus  has 
been  said  to  be  caused  by  it.  And  we  are  of  opinion  that  Dr. 
Eberle's  own  account  of  the  case,  will  furnish  a  sufficient  datum, 
to  rest  this  disbelief  upon.  That  the  woman  laboured  under  te- 
tanus we  have  no  reason  to  doubt,  as  the  symptoms  of  this  af- 
fection are  well  made  out;  but  that  the  disease  was  "  excited  by 
the  irritation  of  a  dead  foetus  in  utero,"  is  far  from  being  proved. 

*  Larrey  has  recorded  the  effects  of  sudden  changes  of  atmospheric  tempe- 
rature, as  they  took  place  in  Egypt.  He  says,  "  I  have  observed  that  this  ac- 
cident, (tetanus,)  did  not  commonly  happen  to  the  wounded,  except  in  such 
seasons,  as  have  rapid  changes  from  one  extreme  of  temperature  to  the  other, 
though  under  similar  circumstances.  Such  of  the  wounded  as  were  exposed 
during  the  night  to  a  cold,  damp  air,  as  the  north,  north  west  winds,  were 
easily  made  to  suffer  from  tetanus,  especially  during  the  spring;  while  on  the 
contrary,  this  disease  rarely  made  its  appearance,  when  the  temperature  was 
uniform,  whether  this  was  during  the  winter  or  summer." — Clin.  Chirur.  Tom. 
1.  p.  90. 

f  But  Rochoux  doubts  the  truth  of  this  assertion.  He  says,  "  le  sexe 
fe"minin,  1'enfance  et  la  jeunesse  y  sont  aussi  plus  exposes  que  le  sexe  mas- 
cidin." 


292  TfcfANUS. 

For  in  the  first  place,  we  have  never  witnessed  more  disturbance1 
in  the  uterine  system  from  a  dead,  than  from  a  living  child;  and 
secondly,  the  very  circumstance,  recorded  by  Dr.  E.  seems  to 
prove,  that  the  tetanic,  and  the  uterine  contractions  were  entirely 
independent  of  each  other;  which  we  think  would  not  have  been 
the  case,  had  the  irritation  of  the  uterus  from  a  dead  foetus,  been 
the  cause  of  the  tetanus;  for  the  Dr.  says,  "I  observed,  that  the 
parturient  contractions  of  the  womb,  and  the  tetanic  spasms, 
recurred  in  regular  alternation.  Now  we  think  this  would 
not  have  been  the  case,  had  the  uterine  irritation  caused  the  te- 
tanic— they  should  have  been  synchronous,  to  have  been  cause 
and  effect;  for  were  this  a  case  of  tetanus  arising  from  the  cause 
assigned,  it  would  come  under  the  division  of  tetanus  from  irri- 
tation ;  and  consequently,  in  this  instance,  the  tetanic  spasm  would 
be  produced  at  the  moment  the  irritation  in  the  uterus  was  great- 
est ;  namely,  during  the  effort  of  explusion  ;  but  this  was  not  the 
case;  for  the  tetanic  and  the  parturient  contractions  "recurred 
in  regular  alternation."  It  is  true  that  Fournier  relates  a  case 
somewhat  analogous.  He  thinks,  from  the  extreme  irritation  of 
the  uterus  and  neighbouring  viscera,  during  a  violent  and  in* 
efficacious  labour,  the  patient  may  be  seized  by  tetanus,  and  de- 
clares he  saw  a  case  of  this  kind,  which  was  immediately  re- 
lieved, by  the  woman  being  relieved  by  artificial  means.  We 
are  however  far  from  considering  this  case,  as  an  instance  of  ge- 
nuine tetanus;  for  we  are  in  the  habit  of  delivering  a  lady,  who 
in  every  labour  she  has  yet  had,  (five,)  is  seized  with  the  most 
Violent  spasms  that  we  have  ever  witnessed  under  such  circum- 
stances. Every  muscle  in  her  body  is  affected  with  the  most 
painful  tetanic  contraction,  that  can  well  be  imagined,  and  which 
will  recur,  whenever  the  contraction  of  the  uterus  takes  place ; 
and  will  continue  until  the  contraction  is  over.  This  sympathetic 
affection,  completely  destroys  the  efficacy  of  the  uterine  pains, 
and  makes  artificial  delivery  always  necessary.  But  this  is 
not  a  case  of  genuine  tetanus^ — for  the  symptoms  cease  the  in- 
stant the  contractions  cease,  and  after  the  child  is  delivered — 
we  believe  these  symptoms  are  produced  by  a  peculiar  distribu- 
tion of  the  sacral  nerves,  on  which  the  head  of  the  child  is  made 
to  impinge  by  the  contractions  of  the  uterus. 

Exciting  Causes. 

$83.  The  exciting  causes  of  tetanus,  are  much  more  evident 
than  the  remote,  or  predisposing.  This  is  the  case,  whether  we 
consider  them  as  acting  by  a  general  influence  without  evident 
lesion  or  irritation;  or  by  producing  structural  derangement  in 
a  greater  or  less  degree.  Dr.  Hennen  says,  that  passion  or  terror 


TETANUS.  293 

after  wounds  and  operations,  have  produced  the  disease  in  some; 
and  sympathy,  though  a  rare  cause,  has  given  rise  to  it  in  others. 

984.  Under  the  first,  we  must  rank  the  sudden  suspension  of 
the  functions  of  the  skin,  as  not  only  the  most  common,  but  also 
the  most  certain — hence  the  liability  to  tetanus  of  those  who 
sleep  in  the  open  air  at  night,  in  tropical,  or  such  warm  climates, 
as  have  the  heat  of  the  day  succeeded  by  considerable  cold  at 
night.     This  cause  may  produce  not  only  what  is  termed  the 
idiopathic  form  of  tetanus,  but  is  also  very  efficient  in  calling 
this  disease  into  action,  when  it  has  been  preceded  by  lesion  of 
some  kind  or  other.  In  this,  all  the  writers  on  tropical  diseases 
seem  to  agree — and  hence  the  frequency  of  both  forms  of  the 
disease  in  St.  Domingo,  Java,  Cuba,  Hispaniola,  Jamaica,  &c. 

985.  Fournier  mentions  a  fatal  case  of  tetanus  in  a  woman, 
that  was  labouring  under  an  acute  gastritis,  who  while  she  was 
bathed  in  sweat,  exposed  herself  in  a  balcony  for  half  an  hour 
to  a  current  of  wind  from  the  north — so  suddenly  and  certainly 
fatal  is  this  kind  of  exposure  in  hot  climates.     The  same  au- 
thority however  proves,  that  similar  consequences  have  followed, 
under  a  great  difference  of  temperature.     A  friend  of  his  was 
seized  with  episthotonos,  by  suddenly  exposing  himself  to  a  cold 
atmosphere  in  winter,  while  he  was  hot  and  sweating  from 
dancing. 

986.  It  is  agreed  upon  all  hands,  that  the  punctured  wound, 
more  certainly  produces  this  disease,  than  any  other  form  of 
wound ;  and  this  is  especially  the  case,  when  the  injury  is  in- 
flicted  by  a  rough  edge  or  point  in   certain  tendinous  parts  of 
the  body;  as  the  soles  of  the  feet,  the  palms  of  the  hands,  the 
wrists,  &c.     It  has  also  followed  amputations;  and  indeed  occa- 
sionally, most  every  kind  of  operation.     I  once  knew  it  brought 
on  in  a  robust  man,  by  running  a  small  thorn  under  the  nail  of 
one  of  his  fingers.     It  has  followed  the  too  closely  paring  of  a 
corn,  &c.  &c.*     Indeed,  it  would  be  endless,  to  detail  all  the 
thousand  causes  named  by  authors;  for  in  this  immensity,  au- 
thors seem  to  have  lost  sight  of  the  fact,  that  if  a.  predisposition 
to  tetanus  exists,  that  a  trifling,  or  even  opposite  agents  may  call 
the  disease  into  action.     There  is  an  obscurity,  nay  an  absolute 
darkness  hanging  over,  the  modus  operand!  of  any  one  of  the  as- 
signed causes  of  tetanus ;  for  it  is  not  by  the  apparent  power  of 
the  agent,  that  we  must  estimate  the  extent  of  its  effects;  for  the 
insignificant  thorn  of  a  blackberry  bush,  has,  (as  in  the  instances 
mentioned  above,)  produced  death  from  tetanus,  as  certainly  and 
as  speedily  as  an  extensive  laceration — while  in  other  cases,  they 
have  failed  to  produce  any  other  than  local  mischief  more  or  less 

*  Dr.  Perry  relates  a  case  of  scalding  followed  by  tetanus. 


294  •  TETANUS. 

grave;  consequently,  there  must  exist  that  certain  condition  of 
part  of  the  nervous  system,  termed  predisposition,  before  either 
exposure  to  cold,  a  puncture,  a  laceration,  or  a  contusion,  shall 
be  followed  by  tetanus — but  in  what  this  consists,  we  are  utterly 
ignorant* 

987.  We  say,  part  of  the  nervous  system  must  be  in  a  state 
of  predisposition  before  tetanic  symptoms  will  show  themselves, 
after  the  application  of  cold  to  the  body,  or  after  it  may  have 
been  wounded;  for  it  is  not  the  entire  system  that  is  affected — 
for  the  muscles,  that  derive  their  nerves  immediately  from  the 
brain,  or  are  supplied  by  the  ganglionic  system,  are  never  pri- 
marily affected  by  tetanic  spasms.     It  is  however  no  less  re- 
markable, than  it  is  difficult  of  explanation,  that  the  fingers  pre- 
serve their  flexibility  to  almost  the  last  moment  of  life. 

Pathology. 

988.  Considerable  attention  has  of  late  been  paid  by  patholo- 
gists,  to  the  investigation  of  the  post  mortem  appearances  of  such 
as  die  of  tetanus — but  hitherto,  no  absolutely  certain  marks  have 
been  discovered.     It  would  seem,  however,  that  the  opinion  of 
Galen,  that  the  disease  was  caused  by  some  derangement  of  the 
spinal  marrow,  has  received  from  modern  research,  much  sup- 
port, if  not  positive  confirmation.  A  long  list  of  highly  respect- 
able names  might  be  adduced,  in  support  of  the  opinion  just  ad- 
vanced; among  those  most  familiar  to  the  medical  reader,  who 
have  espoused  this  doctrine,  are  Le  Gallois,  Abercrombie,Brous- 
sais,  Thompson,  O'Bierne,  Reid,  &c.     Yet  notwithstanding  this 
formidable  array  of  authority  in  favour  of  some  lesion  in  the  spi- 
nal cord  or  its  coverings  being  the  cause  of  tetanus,  it  is  ques- 
tioned by  others,  if  the  appearances  laid  down  by  them,  be  not 
the  effect  of  tetanic  exertion,  rather  than  the  cause.     Larrey, 
though  he  describes  the  pathological  condition  of  the  nerves  and 
spinal  marrow  in  a  manner  very  similar  to  what  has  just  been 
stated,  he  does  not  appear  to  decide  whether  these  appearances 
be  cause  or  effect.     He  says,  "  dans  tous  les  cas,  Pun  des  effets 
les  plus  constans  et  les  plus  intenses  des  causes  qui  produisent  le 
tetanos,  ou  le  tetanos  lui-meme,  est  d'etabler  une  phlegmasie 
plus  ou  moins  etendue,  d'abord  sur  la  Moelle  epiniere  et  le  sys- 

*  Larrey  thinks  that  tetanus  has  often  been  produced  by  including  a  nerve 
in  taking  up  an  artery;  and  that  however  little  consequence  some  may  attach 
to  this  circumstance,  he  is  of  opinion,  that  it  is  productive  of  great  mischief, 
especially  in  climates  favourable  to  the  production  of  tetanus.  He  thinks  that 
mischief  more  certainly  arises,  when  the  ligature  does  not  compress  the  nerve 
very  powerfully;  he  therefore  advises,  in  such  cases  as  do  not  permit  of  the 
omission  of  the  ligature,  that  it  should  be  drawn  very  tightly,  so  as  to  compress 
the  nerve  very  strongly. 


TETANUS.  295 

teme  nerveux  de  la  vie  de  relation,  et  par  suite  sur  celui  des  nerfs 
de  la  vie  interieure  au  moyen  des  rapports  sympathetiques  et  di- 
rects qui  existent  en  grand  nombre  entre  ces  deux  systemes." 
Clinique  Chirurgicale,  torn.  I.  p.  87.*  It  will  therefore  make 
a  cautious  practitioner,  slowly  and  cautiously  to  admit  this 
newly  revived  pathology  of  tetanus — or  until  it  shall  receive 
more  confirmation,  by  a  more  successful  mode  of  treatment,  than 
we  possess  at  present :  for  up  to  this  time  it  must  be  confessed, 
that  our  success  in  treating  this  formidable  disease  is  so  extreme- 
ly limited,  that  the  recoveries  from  it,  may  be  rather  looked 
upon  as  escapes  from  death,  than  the  triumphs  of  art.  For  no- 
thing can  be  more  completely  empirical,  than  the  management 
of  any  given  case  we  may  select,  by  way  of  example ;  and  even 
in  such  cases  as  purport  to  be  cures,  there  is  scarcely  any  simi- 
larity in  the  modes  of  their  treatment.  One  is  said  to  have  been 
cured  by  opium,  another  by  alcohol,  a  third  by  bleeding,  a  fourth 
by  mercury,  &c.  &c.  Yet  unfortunately  for  the  interest  of  hu- 
manity, the  same  remedy  rarely  succeeds  a  second  time  in  any 
body's  hands,  that  may  make  the  trial. 

989.  It  however  cannot  be  doubted,  that  in  very  many  in- 
stances post  mortem  examinations  have  detected  serous  effusions 
at  the  base  of  the  brain,  between  the  tunica  arachoidea,  and  pia 
mater;  the  brain  preternaturally  vascular,  and  ecchymoses,  in 
the  pia  mater ;  coagula  of  blood  between  the  theca  of  the  medul- 
la spinalis  and  the  vertebrae ;  and  in  two  recent  instances,  Dr. 
Perry  found  the  sheaths  of  the  nerves  of  the  injured  part  in- 
flamed, in  several  portions,  and  free  from  it  in  others.  And  this 
account  of  the  state  of  the  brain  and  pia  mater,  is  confirmed  by 
the  observations  of  Larrey,  Fournier,  and  many  others.  And 
more  lately  by  Combette,  who  found  the  following  appearance 
on  the  dissection  of  a  woman  who  died  of  idiopathic  tetanus. 
"On  dissection  thirty  hours  after  death,  there  was  found  great 
vascularity  of  the  cerebral  membranes,  and  somewhat  more  red- 
ness of  the  cerebral  texture  than  natural ;  much  serum  in  the 
canal  of  the  spine ;  the  spinal  membranes,  and  particularly  in- 
side of  the  dura  mater  were  of  a  bright-red  rose  colour ;  the  sur- 
face of  the  cord  covered  with  a  net-work  of  vessels ;  softening  of 
the  anterior  part  of  the  cord,  so  as  to  present  no  resistance  to 
the  knife ;  and  to  form  indeed  throughout  its  whole  length,  a 
semi-liquid  pulp  of  a  lively  rose  colour,  especially  in  the  cervical 
and  lumbar  regions,  where  some  spots  of  extravasation  were  also 
seen."  Amer.  Jour,  of  Med.  Sciences,  for  February,  1832. 

*  If  we  can  believe  Andral,  and  his  familiarity  with  post  mortem  appear- 
ances entitle  him  to  much  confidence.  He  says,  that  in  almost  every  body 
examined  thirty-six  hours  after  death,  reddish  effusions  are  found  in  the  cere- 
bral and  spinal  arachnoid. 


296  TETANUS. 

There  is  besides  much  to  strengthen  the  opinion  of  Galen  in  the 
experiments  of  Le  Gallois,  Wilson  Philip,  &c.,  as  they  could 
produce  tetanic  spasm,  by  irritating  the  spinal  marrow ;  and 
from  all  that  we  have  ascertained  upon  this  subject,  we  are  of 
opinion,  that  the  pathology  of  tetanus  will  be  found  in  some  de- 
rangement of  the  anatomical  structure  of  the  spinal  marrow. 
And  we  may  mention  that  this  opinion  is  much  strengthened  by 
the  experiments  of  Magendie  with  injected  strychnine;  for  no 
sooner  was  this  substance  received  into  the  vein  of  a  dog,  than 
he  became  tetanic,  in  the  most  obvious  sense  of  the  term.  But 
notwithstanding  this  admission,  we  are  far  from  being  sanguine, 
that  a  successful  mode  of  treatment  will  follow  even  a  true  pa- 
thology. And  so  far  at  least,  we  may  say  with  all  safety,  that  the 
remedies  addressed  to  the  spine,  with  the  pathology  just  named 
in  view,  have  failed  of  success  like  every  other  method  hithertode- 
vised  ;  but  whether  this  be  owing  to  the  nature  of  the  agents  em- 
ployed, or  to  the  indomitable  nature  of  the  disease,  remains  yet  to 
be  proved ;  for  Areteus,  centuries  ago,  pronounced  tetanus,  "  ma- 
lum  insanabile;"  nor  has  modern  discovery  contradicted  him. 

990.  We  are  told,  it  is  true,  and  from  authority  that  we  can- 
not doubt,  that  success  has  followed  bleeding,*  from  the  general 
system,  and  locally  from  the  spine  by  leeching,  cupping,  blis- 
tering, cauterizing,  &c.     While  on  the  other   hand,  (and  much 
more  numerously,)  that  the  disease  has  been  cured  by  the  oppo- 
site mode  of  treatment.     Here  the  respective  advocates  of  the 
two  plans  are  at  issue ;  and  it  would  seem  to  prove  either,  that 
the  disease  may  originate  from  opposite  causes,  or  have  opposite 
conditions  of  the  system ;  or  that  nature  sometimes  triumphs 
over  therapeutics.     Or  will  some  new  physiological  law  of  the 
system  be  discovered,  that  will  reconcile  the  present  discre- 
pancies, and  at  the  same  time  confirm  the  most  generally  received 
pathology  of  the  present  day  ! 

991.  Mr.  Swan,  in  his  Essay  on  Tetanus,  locates  the  irritation 
and  inflammation  in  the  ganglia  of  the  great  sympathetic ;  the  se- 
milunar  ganglion  was  highly  injected  with  blood  in  most  of  the 
cases  he  relates ;  and  all  the  other  ganglia  of  this  nerve  bore 
more  or  less  marks  of  inflammation.     The  dissections  of  Dr. 
Perry  neither  confirm  nor  contradict  the  observations  of  Mr. 
Swan.     It  may  however  be  interesting  to  state,  that  in  one  of 
his  cases  of  tetanus  the  disease  was  caused  by  a  lacerated  wound 
of  the  ring  and  middle  fingers,  together  with  the  last  phalanx  of 
the  middle  finger;  the  bruised  fingers  were  removed;  much  pain 

*  Larrey  says,  "  on  examining1  the  bodies  of  such  as  have  died  of  tetanus  I 
have  found  the  pharynx  and  oesophagus  considerably  contracted,  and  their  in- 
ternal coats  red,  inflamed,  and  smeared  with  a  reddish,  viscid  humour."  Cli* 
nique  Chirurgicale,  torn.  I.  p.  87. 


TETANUS.  397 

was  experienced,  which  was  soon  followed  by  tetanus,  which  prov- 
ed fatal  on  the  twelfth  day  from  the  accident.  In  this  case,  "there 
was  no  effusion  on  the  brain  or  its  membranes,  and  its  substance 
was  natural  throughout.  No  effusion  existed  between  the  theca 
and  the  vertebrae;  the  theca  was  healthy,  and  betwixt  it  and  the 
spinal  cord  was  a  preternatural  quantity  of  serum.  The  cord  it- 
self was  of  a  pale  colour.  The  nerves  on  each  side  of  the  re- 
maining phalanx  of  the  ring-finger  were  very  vascular.  On  trac- 
ing upwards  the  ulnar  nerve  from  this  point  to  the  elbow,  it  was 
of  its  natural  colour,  but  here  again  it  became  very  vascular  for 
about  the  extent  of  two  inches.  In  the  axilla  it  again  presented 
a  similar  appearance  as  at  the  elbow,  the  portion  of  it  intervening 
between  these  two  points  being  healthy.  Tracing  the  median 
nerve  in  the  same  way  as  the  ulnar,  it  was  found  perfectly  natu- 
ral, from  its  digital  branch,  which  supplied  the  radial  side  of  the 
ring-finger,  (and  as  just  stated,  was  much  inflamed,)  till  about 
the  middle  of  the  arm,  when  it  again  presented  an  inflamed  ap- 
pearance for  the  extent  of  half  an  inch.  The  portion  of  it  inter- 
vening betwixt  this  part  and  that  confined  to  the  axilla  where  it 
again  became  vascular,  was  natural.  This  vascularity  throughout 
was  not  confined  to  the  sheaths  of  the  nerves,  but  occupied  their 
substance." 

992.  In  this  case,  the  pathological  condition  of  the  brain  and 
nerves,  was  altogether  different  from  the  greater  part  of  those 
reported  of  tetanus.  In  this,  neither  the  brain,  spinal  marrow, 
nor  their  coverings,  were  in  a  morbid  condition;  while  portions 
of  the  nerves  implicated  in  the  accident,  were  in  a  state  of  great 
vascularity,  or  were  inflamed.  And  what  is  most  remarkable  in 
this  case,  was  the  vascular  or  inflamed  condition  of  parts  of  the 
same  nerve,  while  the  intervening  portions  retained  their  healthy 
appearances.  It  is  certainly  altogether  inexplicable,  why  an  anor- 
mal  condition  of  portions  of  a  nerve  should  exist,  and  intervening 
portions  remain  sound ;  and  the  more  especially,  as  that  portion 
immediately  involved  in  the  laceration  was  inflamed  for  two 
inches — the  inflammation  here  ceased  ;  but  was  again  renewed, 
a  few  inches  higher ;  it  was  now  interrupted,  but  again  highly 
vascular,  a  few  inches  beyond.  This  case  also  proves,  that  tetanus 
can  arise  from  an  inflamed  portion  of  a  nerve  quite  remote  from 
its  origin  and  without  implicating  either  that  portion  of  the  spi- 
nal marrow  from  whence  it  proceeded,  or  the  brain  itself.  Does 
it  not  prove  also,  that  we  have  yet  much  to  learn  respecting  the 
laws  of  the  nervous  system  ?  It  must  not  however  be  supposed 
that  a  pathological  condition,  is  confined  to  the  brain  and  spinal 
marrow;  for  both  Larrey  and  Fournier,  whose  opportunities  of 
examination  were  great,  found  the  stomach  and  part  of  intes- 
tines, especially  however  the  colon,  to  be  highly  injected, 

38 


298  TETANUS. 


Diagnosis. 

993.  The  character  of  tetanus  is  so  well  pronounced,  that  there 
is  little  danger  of  its  being  confounded  with  any  other  affection 
of  the  nervous,  or  muscular  systems.     The  tonic  spasm,  or  con- 
tinued rigidity  of  more  or  less  of  the  voluntary  muscles  of  the 
body,  distinguishes  tetanus  from  convulsion,  from  the  latter  be- 
ing attended  by  alternate  spasms,  or  contractions.     It  is  to  be 
distinguished  from  epilepsy,  from  the  latter  always  being  attend- 
ed by  the  total  abolition  of  sensation,  and  of  thought.     From  an 
hysterical  paroxysm,  by  the  remote  and  exciting  cause  of  the 
latter;  by  hysteria  being  a  purely  convulsive  disease — that  is,  by 
its  having  intervals  between  the  spasms,  and  by  its  always  being 
attended  by  the  loss  of  sensation,  and  of  mental   operations; 
though  both  of  these  return,  when  the  spasm  or  convulsion  cease; 
by  hysteria  being  constantly  attended  by  palpitation  of  the  heart, 
globus  hystericus,  and  the  free  discharge  of  limpid  urine.  It  may 
be  distinguished  from  hydrophobia,  from  fever  generally  attend- 
ing this  disease ;  increased  heat  of  body  ;  vomiting  in  the  com- 
mencement; delirium;  and  the  frequent  absence  of  the  lancinating 
pain  from  the  sternum  to  the  spine. 

Prognosis. 

994.  This  disease  has  been  so  uniformly  fatal  under  every  va- 
riety of  treatment,  that  we  are  almost  always  safe,  when  we  de- 
clare, the  chance  of  recovery  to  be  extremely  small.  As  regards 
our  own  experience,  we  candidly  confess,  we  have  never  seen 
but  one  instance  of  recovery  from  tetanus.     We  are  aware,  that 
all  writers, and  commentators  do  not  declare  so  general  a  fatality — 
and  were  we  to  believe  some,  the  results  have  in  their  hands, 
been  very  favourable:  we  pretend  not  to  such  success.* 

995.  It  does  not  appear  that  tetanus  from  cold,t  or  any  other 
cause,  capable  of  producing  this  disease,  without  a  lesion  of  some 
one  part  of  the  body,  is  as  certainly  fatal,  as  where  this  affection 
is  brought  on  by  a  wound  of  any  kind.     But  notwithstanding 
this  general  admission,  the  difference  is  not  perhaps  so  decided 
or  great,  as  to  justify  us  in  a  departure  from  extreme,  or  well 
guarded  caution,  in  pronouncing  upon  the  issue  of  any  given 
case. 

996.  Dr.  Parry  deduces  much  from  the  pulse ;  and  affirms, 

*  See  one  of  the  notes  to  Chapter  on  Tetanus,  in  Gregory's  Practice. 

\  Dr.  Morrison  does  not  agree,  that  traumatic  tetanus,  is  more  fatal  than  the 
idiopathic.  In  this  he  differs  from  almost  every  other  writer;  and  especially, 
from  such  practical  writers  as  Larrey,  Hennen,  Fournier,  &c. 


TETANUS.  299 

that  if  the  pulse  becomes  very  frequent  on  the  first  day  of  the 
disease;  if  it  rise  above  120  beats  in  a  minute,  the  case  may  be 
looked  upon  as  absolutely  fatal.  But  Dr.  Morrison  who  saw 
much  of  tetanus  during  a  residence  of  eight  years  in  Demerara, 
declares  he  never  saw  the  pulse  so  much  accelerated,  as  mention- 
ed by  Dr.  Parry ;  and  we  would  declare  the  same  thing,  were 
our  comparatively  limited  experience  worth  the  naming.  It  is 
true,  we  have  occasionally  known  the  pulse  to  be  much  accele- 
rated, but  we  were  in  the  habit  of  regarding  this  increase  in  fre- 
quency, as  the  effect  of  great  muscular  exertion,  or  contrac- 
tion ;  for  it  has  always  appeared  to  us,  that  as  the  violence  of 
spasm  would  abate,  the  frequency  of  the  pulse  would  diminish. 
Dr.  Morrison  says,  he  never  knew  the  pulse  to  exceed  98,  whe- 
ther the  disease  proved  fatal,  or  terminated  favourably — we  have 
certainly  seen  it  otherways. 

997.  Dr.  Morrison  sums  up  his  experience  with  the  following 
prognostications.  "When  the  disease  comes  on  gradually;  when 
for  the  first  two  or  three  days,  the  muscles  of  the  jaws  are  solely 
affected,  and  that  perhaps,  not  in  any  alarming  degree ;  when  the 
abdomen  is  not  preternaturally  hard,  nor  the  bowels  obstinately 
costive ;  when  the  skin  is  moist  and  moderately  warm,  and  above 
all  when  the  patient  enjoys  sleep,  we  may  entertain  strong  hopes 
of  recovery.  An  increased  flow  of  saliva,  whether  the  patient 
has  or  has  not  used  mercury,  is  always  to  be  regarded  as  favour- 
able ;  the  less  the  general  air  of  the  countenance  is  changed  the 
better.  On  the  other  hand,  when  the  attack  is  sudden  and  vio- 
lent; when  the  muscles  of  the  neck,  back,  and  abdomen,  are 
rigidly  contracted;  when  the  patient  complains  of  a  shooting 
pain  from  the  sternum  towards  the  spine;  when  the  belly  feels 
hard  like  a  board,  and  the  least  pressure  thereon  produces  spas- 
modic twitchings,  or  contractions  of  the  muscles  of  the  neck, 
jaws,  &c.  or  when  the  same  effect  is  brought  about  by  the  pre- 
sentation of  any  substance,  (solid  or  fluid,*)  near  the  mouth,  we 
have  much  reason  to  fear  a  fatal  termination.  Spasmodic  start- 
ings  of  the  muscles  set  in  sometimes  early  in  the  disease,  and 
recurring  every  eight  or  ten  minutes,  are  to  be  regarded  as  very 
unfavourable."  p.  29.  Dr.  M.  does  not  think  that  traumatic 
tetanus  is  sq  fatal  in  tropical  climates  as  authors  generally  repre- 
sent ;  and  believes,  from  a  case  of  this  kind  yielding  to  the  efforts 
of  nature,  that  spontaneous  cases  of  cure  do  occasionally  occur 
in  these  climates — we  however  have  never  heard  of  such  an 
instance  in  this  country.  Trismus,  generally  speaking,  is  the 

*  Larrey  says,  when  tetanus  presents  itself  in  its  most  exalted  form,  some 
remarkable  symptoms  present  themselves.  Sometimes  the  patient  shows  the 
greatest  possible  aversion  to  liquids;  and  should  he  be  forced  to  swallow  any, 
it  will  cause  the  most  violent  convulsions.  Clinique  Chirurgicale,  Tom.  I.  p.  86. 


300  TETANUS. 

least  fatal  form  of  tetanus.  But  when  the  disease  becomes  pro- 
tracted, the  pulse  keeping  regular,  and  the  skin  maintains  its 
warmth,  it  is  favourable;  especially,  if  the  patient  can  receive 
drinks,  and  the  bowels  become  free.  A  free  perspiration  succeed- 
ing to  a  hot  skin ;  a  bleeding  from  the  nose,  or  a  return  of  a 
haemorrhoidal  flux,  are  also  good  signs. 

Treatment. 

998.  We  believe  no  one  has  attempted  any  difference  in  treat- 
ment for  the  idiopathic  or  the  traumatic,  nor  for  the  different 
species  into  which  nosological  writers  have  divided  tetanus. 

999.  The  treatment  consists  in  the  use  of  topical  applications, 
and  general  or  constitutional  remedies.     The  objects  to  be  ful- 
filled by  the  first,  are  inflammation  and  suppuration — hence  the 
employment  of  the  sp.  tereb.  lunar  caustic;  caustic  lye,  actual 
cautery,  cantharides,  &c.  emollient  poultices,  to  aid  or  hasten 
suppuration;  warm  olive  oil,  &c.     The  division  of  half  divided 
nerves,  or  tendons,  has  been  recommended;  but  who  would  pro- 
mise himself,  that  he  could  ascertain  in  any  given  wound,  that 
a  portion  of  a  nerve  was  left  undivided,  or  that  he  could  succeed 
in  completing  the  division,  and  at  the  same  time  not  place  some 
other  nerve  with  which  his  knife  may  come  in  contact,  in  the 
same  predicament  ?  We  believe  this  attempt  can  rarely  be  avail- 
ing in  any  instance ;  and  that  it  may  be  in  others  highly  inju- 
rious.  But  not  exactly  so  with  regard  to  a  partially  divided  ten- 
don ;  as  this  may  sometimes  be  evident  to  the  sight,  and  its  divi- 
sion may  be  important.     Larrey  advises  the  amputation  of  an 
extremity,  not  merely  because  there  is  much  loss  of  substance, 
or  the  bones  comminuted,  or  other  causes  that  may  render  this 
operation  necessary,  but,  as  a  preventive  to  many  serious  evils, 
but  especially,  tetanus.     He  also  recommends  the  division  of  a 
ligature,  when  it  includes  a  nerve  with  the  artery.     He  appears 
to  have  performed  this  delicate  operation  several  times,  with 
manifest  advantage — but  this  is  the  business  of  the  surgeon. 

1000.  As  regards  our  own  experience,  we  have  never  seen 
either  stimulating  applications,  or  the  dilation  of  the  wound,  of 
the  slightest  use.     In  a  case  that  fell  under  the  notice  of  Dr. 
Physick  and  ourselves,  we  succeeded,  by  dilating  the  wound 
and  stimulating  it  with  sp.  tereb.  to  bring  on  suppuration;  but 
the  patient  died  on  the  sixth  day  after  the  symptoms  first  showed 
themselves.     Yet  we  will  not  positively  assent  this  plan  cannot 
be  useful.     Nor  does  it  appear,  from  the  experience  of  Larrey  or 
Hennen,  that  the  removal  of  the  part  in  which  the  lesion  exists, 
is  attended  with  any  remarkable  benefit,  though  occasionally 
useful. 


TETANUS.  301 

1001.  Dr.  Potter  appears  to  us,  to  be  much  at  variance  with 
himself,  in  his  note  affixed  to  the  text  of  Dr.  Gregory  on  the 
subject  of  tetanus.     He  says,  "  the  less  the  inflammation  in  the 
wounded  part,  the  greater  is  the  danger  of  tetanus."     But  he 
immediately  adds,  "  the  practice  of  endeavouring  to  excite  high 
inflammation  in  the  part  originally  hurt,  has  been  very  generally 
adopted,  and  we  believe  without  benefit,  and  probably  it  has 
operated  injuriously.     Instead  of  mitigating  the  ferocity  of  spas- 
modic contraction,  it  frequently  foments  it."  Much  dependence 
however  is  placed  upon  a  healthy  suppuration  in  the  wounded 
part;  for  say  they,  when  this  happens,  the  disease  usually  relaxes, 
and  the  amendment  is  attributed  to  this  cause.  We  are  however 
very  doubtful  of  the  agency  of  a  suppurating  surface  in  taming 
the  ferocity  of  tetanic  spasms.     We  look  upon  this,  as  mere  co- 
incidence ;  or  only  as  marking  a  return  of  the  healthy  functions 
of  the  body ;  and  that  the  appearance  of  healthy  pus,  is  the  con- 
sequence of  the  abatement  of  the  morbid,  or  tetanic  action,  and 
not  the  cause  of  it — and  that  "post  hoc,  ergo,  propter  hoc," 
is  too  frequently  made  the  basis  of  medical  reasoning,  or  of  the- 
rapeutical suggestions. 

1002.  By  way  of  preventive  Dr.  Clark  recommends  a  slight 
mercurial  ptyalism  to  be  brought  on  after  wounds  in  hot  climates. 

1003.  The  general  remedies  mainly  relied  upon,  are  opium, 
mercury,  cold  and  warm  bath,  bark  and  wine,  cathartics,  blis- 
ters, spirit  of  turpentine,  caustics,  musk,  asafoetida,  &c.  We  shall 
therefore  consider  each  of  these  therapeutical  agents  separately. 

1004.  Opium. — There  is  no  remedy  in  tetanus,  that  has  so 
much  testimony  in  its  favour,  as  opium ;  yet,  it  is  but  too  well 
ascertained,  that  it  cannot  be  always  relied  upon.     Popular  pre- 
judice in  its  favour  is  so  great,  that  a  practitioner,  would  scarcely 
be  considered  free  from  blame,  that  did  not  employ  it,  notwith- 
standing its  frequent  failure.  It  would  be  easy  to  bring  authorities 
of  high  standing,  for  its  almost  unlimited  employment,  and  ap- 
parently for  its  efficacy  in  the  disease  in  question ;  while  on  the 
other  hand,  we  could  with  equal  facility  adduce  evidence  equally 
entitled  to  confidence,  that  utterly  condemn  it  as  useless,  if  not 
pernicious.     As  regards  our  own  experience,  we  are  obliged  to 
confess  we  have  never  seen  it  of  the  slightest  service,  either  as  a 
palliative  or  as  a  remedy. 

1005.  Thus  we  find  Cullen,  and  almost  all  his  followers,  place 
their  chief  reliance  on  opium,  and  recommend  it  to  be  given  with 
unsparing  hand.     Dr.  Barr*  gave  one  drachm  of  solid  opium  on 
the  third  day  of  the  disease,  and  after  the  loss  of  eighty-two 
ounces  of  blood.  Dr.  Morrison  employed  this  drug  in  Demarara 

•  Edinburgh  Med.  and  Surg.  Jour.  No.  XVII. 


302  TETANUS. 

with  a  liberal  hand,  and  apparently  with  advantage.  While 
Broussais,  Larrey,  Fournier,  Hennen,  &c.  are  averse  from  its 
employment.  The  young  practitioner  will  thus  find  nothing  but 
conflicting  testimony  on  the  subject  of  opium  ;  nor  can  we  re- 
lieve it,  by  either  our  own  experience,  or  by  any  new  patholo- 
gical or  therapeutical  views.  We  can  only  say,  if  this  article  be 
employed,  the  stronger  evidence  is  in  favour  of  large  and  suffi- 
ciently often  repeated  doses,  and  this  in  the.form  of  laudanum; 
as  there  is  too  much  reason  to  believe,  that  many  have  fallen 
victims  to  the  remedy,  rather  than  the  disease,  when  given  in  the 
form  of  opium:  for  its  insolubility  in  the  stomach  has  permitted 
a  deadly  quantity  to  be  accumulated  in  the  stomach  before  its 
narcotic  effects  were  made  manifest.  We  believe  also,  it  will  be 
found  that  per  anum  will  be  the  most  certain  way  of  its  getting 
possession  of  the  system.  One  hundred  drops  of  laudanum  has 
generally  been  considered  a  proper  dose  by  the  mouth,  and  if  it 
be  applied  to  the  rectum,  this  quantity  should  be  trebled.  Might 
not  a  suppository  of  half  a  drachm  of  opium  be  an  eligible  mode 
of  administering  it? 

1006.  Mercury. — As  regards  this  remedy,  the  same  conflict- 
ing testimony  meets  us  at  the  very  threshold.     Larrey  tells  us 
it  invariably  did  harm  in  Egypt;  while  the  Monro's  declare  they 
have  succeeded  with  it  most  happily.     Dr.  Rush  records  a  case 
that  was  cured  by  mercury,  aided  by  bark  and  wine.    Dr.  Mor- 
rison informs  us,  that  he  met  "  with  many  examples  of  the  bene- 
ficial effects  of  mercury  in  this  disease,  and  as  it  does  not  inter- 
fere with  any  other  remedies,  the  free  administration  of  it,  he 
says,  ought  never  to  be  omitted."     Treatise  on  Tetanus.     Dr. 
Johnson  says,  spontaneous  salivation  has  often  been  observed  in 
tetanic  patients  whose  cases  terminated  favourably,  hence,  pro- 
bably, the  first  idea  of  using  mercury.* 

1007.  That  mercury  may  be  useful,  it  should  be  early  and 
liberally  employed — and  this  both  by  inunction,  and  in  the  form 
of  calomel  by  the  mouth;  for  unless  ptyalism  be  produced,  we 
believe  it  will  never  be  efficient;  and  in  most  instances  of  trau- 
matic tetanus  especially,  we  fear  that  the  system  will  be  too 
much  under  the  influence  of  tetanic  impression,  or  that  the  pa- 
tient will  die  before  the  mercurial  action  will  be  set  up.  We  can 
say  nothing  of  the  use  of  mercury  in  this  disease  from  our  own 
experience,  that  will  instruct  in  its  application,  or  would  deter 
from  its  employment. 

1008.  Dr.  Morrison  recommends,  that  four  grains  of  calomel 
should  be  given  two  or  three  times  a  day,  also,  three  or  four 
drachms  of  the  ointment  well  rubbed  on  the  neck  and  spine, 

*  Influence  of  Tropical  Climates,  &c. 


TETANUS.  303 

night  and  morning,  besides  a  much  larger  quantity  to  be  rubbed 
upon  other  portions  of  the  body.  We  are  disposed  however  to 
fear,  that  mercury  when  it  salivates,  rather  proves  the  mildness 
of  the  character  of  the  disease,  than  its  controul  over  it* 

1009.  Warm   and  cold  bath. — Fournier  thinks   that  ad- 
vantage might  be  derived  from  the  alternate  use  of  the  warm 
and  cold  bath.     He  says  the  patient  should  be  kept  in  the  warm 
bath  for  about  a  quarter  of  an  hour,  and  then  a  certain  quantity 
of  very  cold  water  should  be  suddenly  poured  upon  the  head. 
He  thinks  this  plan  would  be  highly  useful,  where  the  muscles 
of  the  head  and  neck  are  very  rigid;   the  pulse  full;  and  when 
the  brain  betrays  marks  of  sanguine  congestion — however  con- 
fesses he  has  never  tried  this  plan  himself,  though  it  has  been 
used  with  success  by  others. 

1010.  Dr.  Morrison  also  thinks  favourably  of  this  remedy — 
he  says  it  has  afforded  much  present  relief,  in  a  number  of  in- 
stances in  which  it  was  employed  when  the  spasmodic  twitchings 
were  frequent  and  troublesome. 

1011.  This  treatment  may  be  had  recourse  to  in  hospital  prac- 
tice ;  but  it  could  be  very  rarely  used  with  advantage  in  private 
families.  Indeed  Dr.  M.  himself  seems  to  have  but  little  reliance 
upon  it — and  intimates  that  the  exertion  the  patient  is  obliged 
to  make  in  employing  this  remedy,  counterbalances  the  good  ef- 
fects expected  from  it. 

1012.  Bark  and  wine. — We  believe  these  remedies  are  very 
rarely  relied  upon  alone — they  form  a  part  of  the  routine  of  me- 
dical discipline,  to  which  a  tetanic  patient  is  almost  unavoidably 
exposeM:  at  most  they  can  be  considered  but  as  auxiliaries  to 
other  more  efficient  means. 

1013.  Purging. — We  believe  that  purging  has  never  been 
exclusively  relied  upon  in  tetanus;  though  all  confess  its  import- 
ance as  an  auxiliary.   We  have  already  remarked  upon  the  state 
of  constipation  to  which  the  bowels  are  liable,  either  as  one  of 
the  characters  of  the  disease,  or  as  a  state  brought  on  by  the  re- 

*  The  experiments  of  Mr.  Swan  with  a  view  to  illustrate  the  pathology  of 
tetanus,  have  elicited  a  curious  fact  as  respects  the  influence  of  mercury  upon 
the  ganglia.  "In  experiments  upon  animals,  I  have  found  decided  marks  of 
inflammation  of  the  ganglia  of  the  grand  sympathetic  nerves  produced  by  mer- 
cury. As  there  is  a  similar  appearance  of  the  ganglia  in  tetanus,  I  cannothelp 
supposing,  that  the  use  of  mercury  is  very  doubtful,  if  not  altogether  hazard- 
ous; and  so  many  cases  on  record,  in  which  it  has  failed  to  restrain  the  disor- 
der, show  that  it  cannot  by  any  means  be  depended  on.  I  am  willing  to  be- 
lieve that  practitioners  may  have  thought  it  beneficial,  because  a  patient  who 
has  used  it  has  recovered.  I  have  seen  it  administered  in  chronic  tetanus,  and 
the  patient  has  got  well;  but  the  recovery  was  very  slow;  and  whether  it  had 
any  influence  over  the  disease,  is  most  difficult  to  determine."  Essay  on  Te- 
tanus, founded  on  cases  and  experiments. 


304  TETANUS. 

medy  so  universally  employed  in  this  disease,  namely,  opium.* 
And  all  agree  that  it  is  a  condition,  be  it  accidental,  or  charac- 
teristic, that  is  very  difficult  to  overcome.  Sir  James  M'Grigor 
informs  us,  that  the  operation  of  calomel  has  always  been  useful, 
especially  in  the  mild  forms  of  tetanus.  But  the  more  active 
purgatives  seem  to  claim  a  preference — and  perhaps  none  is  more 
certain  in  its  operation,  or  more  easy  of  exhibition,  than  the 
croton  oil,  mixed  with  a  mucilage  of  gum  Arabic,  and  some  one 
of  the  essential  oils.t  The  infusion  of  tobacco  has  also  been  re- 
commended in  enemata — we  have  seen  a  fair  trial  made  of  this 
remedy;  but  without  the  least  advantage  to  the  disease,  though 
not  without  great  annoyance  to  the  patient.  As  a  mere  purga- 
tive injection,  when  other  remedies  have  failed  to  procure  a  dis- 
charge from  the  bowels,  it  may  be  useful.  Dr.  Hennen's  tes- 
timony, is  very  similar  to  the  one  we  have  just  expressed.  It 
must  however  always  be  kept  in  mind,  that  the  doses  of  every  me- 
dicine that  we  may  employ  in  tetanus,  should  be  at  least  doubled. 
1014.  Spirit  of  turpentine. — There  is  as  much,  if  not  more 
substantial  evidence  in  favour  of  this  drug,  as  any  that  has  gene- 
rally been  employed ;  and  to  corroborate  this,  we  may  with  much 
propriety  refer  to  the  case  related  by  Dr.  Mott,  of  New  York.J 
This  was  a  case  of  traumatic  tetanus,  and  had  resisted  all  the 
usual  means.  A  tea-spoonful  of  the  turpentine  was  given  every 
fifteen  minutes  for  the  period  of  two  hours — at  the  end  of  this 
time,  the  spasms  ceased.  The  turpentine  was  now  given  at 
more  distant  periods,  until  one  hundred  and  twenty-three  doses 
were  given  in  thirty-six  hours.  This  substance  is  one  of  great 
power,  and  well  deserves  further  trials ;  and  when  it  is  combined 
in  equal  quantities  with  castor  oil,  it  is  one  of  the  most  certain 
and  active  of  the  purgatives. 

*  Dr.  Hennen  says  he  has  never  witnessed  any  one  symptom  detailed  by 
authors  to  be  constantly  present  in  tetanus,  save  costiveness — it  would  seem 
from  this,  that  this  state  of  the  bowels  is  one  of  the  absolute  characters  of  the 
disease,  and  the  only  one,  constantly  present. 

f  We  have  never  employed  the  croton  oil  in  tetanus,  though  we  have  fre- 
quently used  it  in  other  obstinate  cases  of  constipation.  Our  usual  formula  for 
an  adult  is  as  follows: — 

R.     Ol.  croton  tig.  ....         gut.  viij.  vel.  x. 

Mucil.  g.  Arab.        ....         gjj. 
Ol.  anise  vel.  carui  -  gut.  iv. 

Sacch.  alb. sjij.  M. 

Of  tills  a  tea-spoonful  is  given  every  hour  until  it  operates  freely.  In  teta- 
nus, however,  the  dose  may  be  profitably  increased  perhaps  to  two  drops 
at  a  dose. 

$  We  might  mention  other  cases  in  favour  of  the  turpentine;  for  instance, 
those  of  Mr.  Hutchinson,  Mr.  Torrs,  &c.  but  Mr.  H's  case  appears  rather  a 
doubtful  one,  as  it  had  been  preceded  by  epilepsy,  though  that  of  Mr.  Torrs 
is  free  from  this  objection. 


TETANUS.  305 

1015.  Caustics. — From  the  pathology  now  generally  accept- 
ed, caustic  applications  have  been  used  to  the  spine.     Dr.  Rush 
saw  it  succeed"  in  two  instances  in  combination  with  the  cold 
bath  in  the  horse.     Dr.  Hartshorne  of  our  city,  we  believe  was 
the  first  who  used  it  on  the  human  subject  in  this  country;  and 
his  example  was  successfully  followed  by  a  number  of  practi- 
tioners.    We  have  used  it  once,  but  in  that  instance  it  failed  to 
even  mitigate  suffering,  or  to  prolong  existence.     The  mode  of 
using  it,  is  by  dipping  a  piece  of  sponge  tied  upon  a  stick  or  fork, 
in  a  strong  solution  of  caustic  alkali,  and  then  rubbed  upon  the 
spine  until  it  excite  inflammation. 

1016.  Musk. — Of  this  remedy,  we  can  say  nothing  from  our 
own  experience ;  its  extreme  high  price  forbids  its  employment 
in  private  practice ;  and  its  doubtful  efficacy,  scarcely  would  lead 
to  its  use,  did  we  waive  the  objection  of  price.     Yet  Fournier 
speaks  of  its  virtues  in  almost  unmeasured  terms.     He  says, 
"  musk,  of  all  the  antispasmodics  appears  to  me  to  possess  the 
greatest  activity  and  power.     I  have  employed  it  with  great 
success  in  divers  cases  of  tetanus.     I  gave  from  one  to  two 
drachms  daily,  in  doses  of  from  ten  to  fifteen  grains." 

1017.  JlsGfcRtida. — This  substance  is  certainly  too  feeble  to 
be  relied  upon  as  a  principal  remedy — if  it  be  useful,  it  must  be 
after  the  more  violent  spasms  have  yielded  to  other  remedies — 
this  appears  to   have  been   its  agency,  in  a  case  related  by 
Dr.F. 

1018.  We  have  thus  passed  in  review  the  principal  remedies 
recommended  for  the  relief  of  this  truly  cruel  and  fatal  disease, 
without  our  reliance  being  increased  in  any  one  of  the  given  means. 
For  if  we  are  honest  in  making  our  summary,  we  are  obliged  to 
confess,  that  there  is  such  equality  of  testimony  in  favour  of  each 
individual  plan,  as  to  at  least  perplex  our  judgment,  if  not  to  pre- 
vent a  selection.     Let  us  hear  what  the  honest  and  experienced 
Hennen  says  upon  this  subject. 

1019.  "  Happy  should  I  be  could  I  afford  any  thing  satisfac- 
tory on  this  dreadful  complaint;  but  in  truth,  my  observations 
have  tended  more  to  show  me  what  I  could  not  trust  to,  than 
what  I  could  place  the  smallest  reliance  on,  when  the  disease 
was  once  fully  formed."  Military  Surgery,  p.  148.     And  we 
are  of  opinion,  that  this  will  be  the  confession  of  every  honest  prac- 
titioner.   As  regards  our  own  experience,  we  freely  confess  that 
we  never  succeeded  but  once  in  curing  tetanus;  and  this  was  ef- 
fected by  keeping  up  a  slight  intoxication  by  means  of  hot  rum 
punch  for  several  days  consecutively — but  this  remedy  failed 
utterly  in  the  very  next  case,  in  which  it  was  employed.     Dr. 
Hennen  in  the  next  page,  declares  he  had  never  been  so  fortunate 
as  to  cure  a  case  of  acute  sympathetic  tetanus — we  believe,  that 

39 


306  HYDROPHOBIA. 

if  every  practitioner  had  been  equally  candid,  we  should  hear  of 
fewer  cures.* 

1020.  It  may  be  proper  and  useful  to  remark,  that  the  patho- 
logy now  almost  universally  believed  in,  namely,  inflammation, 
in  the  cerebral  meninges,  and  especially  in  the  spinal  marrow 
or  its  theca,  is  supposed  by  some  to  be  contradicted  or  disproved, 
by  such  cases  as  are  said  to  have  been  cured  by  powerful  stimuli. 
Upon  this  objection  to  the  best  established  pathology,  Dr.  John- 
son remarks,  and  we  think  with  much  propriety,  "  that  the 
local  abstraction   of  blood    by  leeches  and    cupping  from   the 
neighbourhood  of  the  spine,  with  subsequent  blisters  there,  are 
not  inconsistent  with  the  plan  of  treatment  recommended  by  Dr. 
Morrison.  For  it  must  be  remembered,  that  such  is  the  unequal 
distribution,  both  of  blood  and  excitability  in  the  system  under 
this  disease,  that  one  part  is  completely  torpid,  while  another  is 
on  the  point  of  extravasation  from  turgescency  or  inflammation. 
It  is  evident  from  this  view  of  the  affair,  that  we  must  stimulate 
the  torpid  organs  at  the  very  moment  we  are  employing  seda- 
tives and  counter-irritants,  or  abstracting  blood  from  the  congest- 
ed parts.     Hence,  too,  the  value  of  purgatives  and   mercury. 
The  former  bring  back  the  excitement  to  the  abdominal  viscera, 
and  powerfully  determine  from  the  spine;  the  latter  sets  all  the 
secretory  and  excretory  apparatus  to  work,  while  it  equalizes 
the  circulation  in  every  part  of  the  system."     Influence  of  tro- 
pical diseases  on  European  constitutions,  p.  513. 

SECT.  VII. — HYDROPHOBIA. 

1021.  Dr.  Cullen  dismisses  the  subject  of  hydrophobia  in  two 
pages;  he  says,  "  with  respect  to  its  pathology,  I  find  I  can  say 
nothing  satisfying  to  myself,  or  that  I  can  expect  to  prove  so  to 
others."     He  places  it  immediately  after  hysteria,  to  which  it 
has  no  natural  analogy.      Its  cause,  its  progress,  its  symptoms, 
its  termination,  and   proposed   methods  of  cure,  bear  not  the 
slightest  resemblance  to  hysteria.     He  ranks  it  among  the  spas- 
modic affections ;  Dr.  Rush  among  fevers,  and  Boerhaave  pro- 
nounced it  "summeinflammatorious;"  while  most  of  the  modern 
practical  writers  make  it  follow  tetanus,  to  which  it  has  some 
affinity,  if  symptoms  will  justify  application.     Yet  its  general 
character  and  causes  differ  toto  ca?lo  from  tetanus — for  tetanus  is 
not  a  disease  of  specific  contagion;  nor  can  it  be  propagated  in 
another  subject  by  any  means  of  art.     Hydrophobia  in  the  hu- 
man subject,  is  always  the  result  of  wounds  inflicted  by  a  rabid 

*  Dr.  O'Beirne  declares  of  two  hundred  cases  of  traumatic  tetanus  that  oc- 
curred in  the  Peninsular  army,  not  one  recovered. — Dub.  Hosp.  Rep.  Vol.  III. 


HYDROPHOBIA.  307 

dog,  or  by  an  animal  of  this  genus — as  the  wolf,  the  fox,  the 
jackal],  and  the  hyena. 

1022.  It  is  however  taught  and  believed  by  some,  that  this 
disease  can  be  propagated  by  any  animal  that  is  labouring  under 
the  hydrophobic  action ;  this  however  should  not  be  too  easily 
admitted,  nor  be  unadvisedly  rejected.     We  have  seen  but  few 
cases  of  this  awful  disease — not  more  perhaps  than  a  dozen  ;  in 
each  of  these  instances,  it  was  by  the  bite  of  a  dog.    In  1792  we 
had  a  large  mastiff  to  go  mad — he  bit  a  very  near  friend  on  the 
bare  arm,  and  left  the  trace  of  one  of  his  teeth  for  at  least  three 
inches,  from  which  some  blood  flowed  the  whole  length  of  the 
wound.     The  dog  ran  from  the  house,  and  in  the  course  of  his 
wanderings  he  bit  fourteen  animals,  a  number  of  which,  if  not 
all,  went  mad;  but  in  no  one  instance  did  we  hear  of  its  being 
by  any  accident  propagated  further — the  disease  stopped  with 
these  victims,  for  such  they  proved.     It  is  true  this  does  not 
amount  to  proof  that  either  of  these  animals  could  propagate  the 
disease;  yet  we  believe  that  much  mischief  would  have  ensued, 
had  these  bites  been  inflicted  upon  dogs.* 

1023.  But  what  shall  we  say  to  the  testimony  of  Dr.  Potter,t 
who  gravely  tells  us,  that  it  is  within  his  own  knowledge,  "  that 
a  cow,  a  sheep,  a  hog,  a  goose"  has  communicated  the  disease. 
In  these  cases,  we  are  of  opinion,  there  is  much  room  to  doubt, 
that  the  affections  which  followed  the  bite  of  these  animals  were 
genuine  cases  of  rabies.     If  the  dread  of  water  be  taken  as  the 
pathognomonic  symptom  of  this  disease,  much  confusion  will  be 
created;  for  Dr.  Good  informs  us,  that  he  had  a  young  lady  as  a 
patient  who  had  the  dread  of  water  to  a  great  degree,  and  the 
same  has  been  witnessed  by  others.     It  is  true  that  Dr.  Potter 
may  find  an  apparent  support  in  the  cases,  (every  way  similar,) 
quoted  by  Dr.  Good  from  Le  Cat  and  others;  but  it  is  well 
known  how  given  to  the  marvellous  were  the  writers  of  the  last 
century,  and  how  little  reliance  can  be  placed  upon  the  accounts 
where  there  feelings  could  be  exercised;  though  Dr.  G.  to  ob- 
viate this  prominent  objection  says,  "  marvellous  as  these  facts 
appear,  it  is  more  consistent  with  reason  to  accredit  them  than 
to  impugn  the  host  of  authorities  to  whose  testimony  they  ap- 
peal." p.  231,  Vol.  III.     Yet  after  this  apology  for  the  won- 
derful, Dr.  G.  forgets  it  immediately,  and  says,  "  now  the  only 
animals  which  have  hitherto  been  ascertained  to  have  a  power  of 
generating  it  are  several  species  of  the  genus  canis,  as  the  dog, 

*  In  the  case  just  alluded  to,  the  lady  escaped  by  the  exertions  we  made  to 
prevent  the  absorption  of  the  virus,  or  its  tarrying  on  the  wounded  places.  The 
wounds  were  immediately  well  and  frequently  washed  with  a  strong  solution 
of"  newly  made  soft-soap  and  warm  wsiter  during  several  hours — no  other  pre- 
caution was  used. 

f  Note  to  Gregory's  Practice,  p.  149. 


308  HYDROPHOBIA. 

fox  and  wolf,  and  species  of  the  genus  felis,  which  is  the  domes-1 
tic  cat;  it  is  probable  however,  there  are  others  belonging  to 
different  classes  endowed  with  a  like  power ;  and  some  writers 
have  attempted  to  bring  instances  from  the  horse,  mule,  ass,  ox, 
and  hog,  yet  they  are  not  instances  to  be  depended  upon." 

1024.  Dr.  Gregory  says,*  "  the  disease  almost  always  com- 
mences among  animals  of  the  canine  race."     We  wish  he  had 
gone  a  little  further,  and  have  said  "always" — for  we  believe 
this  disease  in  its  origin  to  be  peculiar  to  the  dog  kind,  and  must 
originate  therefore  with  them ;  for  we  do  not  know  an  unques- 
tionable instance  of  its  originating  in  any  other  animal.     Dr. 
Gregory  further  says,  "  it  is  even  questionable  how  far  it  ever 
originates  even  in  the  cat  kind.t     To  them  however  it  is  easily 
propagated,  and  they  possess,  equally  with  dogs,  the  power  of 
transmitting  it  to  man,  and  to  every  species  of  quadruped.     It 
is  a  matter  of  doubt  whether  birds  are  susceptible  of  the  disease. 
Herbivorous  animals,  appear  incapable  of  communicating  it,  and 
this  is  even  still  better  ascertained  with  regard  to  man.     Innu- 
merable attempts  have  been  made  to  propagate  the  disease  by 
inoculating  animals  with  the  saliva  of  persons  labouring  under 
hydrophobia,  but  they  have  all  failed." 

1025.  This  assertion  however  appears  to  be  too  broad,  if  there 
be  no  mistake  in  the  experiments  of  Magendie  and  Breschet, 
which  it  would  seem  there  cannot  well  be,  as  the  relation  of  the 
result  bears  every  mark  of  authenticity.   They  collected  a  quan- 
tity of  the  saliva  of  a  man  labouring  under  hydrophobia,  which 
was  inserted  beneath  the  skin  of  two  dogs  apparently  in  perfect 
health.    Thirty-eight  days  after  this  inoculation,  one  of  the  dogs 
became  rabid,  and  bit  two  other  dogs,  one  of  which  died  a  month 
after  of  the  same  disease. 

1026.  This  disease  is  always  communicated  to  man  by  inocu- 
lation by  wounds  made  by  the  teeth  or  a  tooth  of  the  animal  im- 
bued with  the  saliva  ;J  it  is  never  spread  by  the  atmosphere  in 

*  Practice  of  Physic,  Vol.  II.  p.  148. 

-j-  Dr.  Good  appears  to  believe,  that  the  disease  becomes  milder  by  passing- 
through  the  constitution  of  the  domestic  cat,  after  the  same  manner  as  the 
small-pox  virus  does,  after  having  passed  through  the  system  of  one  who  had 
been  protected  by  the  vaccine  disease.  Study  of  Med.  Vol.  III.  p.  235. 

$  The  instance  mentioned  by  Dr.  Rush  as  an  exception  to  this  rule  is  too 
vague  to  be  set  in  opposition  to  the  experience  that  declares,  "  a  wound  is 
absolutely  required."  Dr.  Rush  did  not  see  the  case  he  makes  mention  of — 
he  only  says,  "I  have  heard  of  a  case  in  Lancaster  county,  Pennsylvania,  in 
which  a  severe  contusion,  by  the  teeth  of  the  rabid  animal,  without  the  effu- 
sion of  a  drop  of  red  blood,  excited  the  disease."  Works,  Vol.11,  p.  302. 
Now  we  do  not  believe  that  the  "  effusion  of  a  drop  of  red  blood"  is  ever  ne- 
cessary to  the  propagation  of  this  disease;  a  solution  of  continuity  in  the  epi- 
dermis is  all  that  is  required.  For  in  the  inoculation  for  the  small-pox,  or  for 
the  vaccine  disease,  it  is  more  sure  to  succeed  when  there  is  not  "  the  effusion 
of  a  drop  of  red  blood,"  than  when  this  happens. 


HYDROPHOBIA.  3Q9 

which  the  subject  breathes,  most  fortunately  for  the  human  suf- 
ferer, as  it  does  not  deprive  him  of  the  affectionate  attentions  of 
his  friends,  while  labouring  under  this  awful  affliction.  And  still 
more  fortunately  perhaps  is  the  circumstance,  that  very  many  . 
escape  the  disease  who  may  have  been  bitten — this  however  cer- 
tainly arises  from  the  human  subject  being  bitten,  for  the  most 
part,  in  parts  covered  by  clothing,  rather  than  from  the  want  of 
power  in  the  virus;  for  so  obviously  is  this  the  case,  that  few 
animals  escape  this  malady  that  have  been  bitten ;  while  in  the 
human  subject,  comparatively  few  are  attacked  with  hydropho- 
bia, unless  the  bite  be  upon  an  exposed  or  naked  part.  Mr. 
Hunter  relates  a  remarkable  instance  of  an  immunity  of  this 
kind ;  for  of  twenty  persons  bitten  by  the  same  rabid  animal, 
only  one  suffered. 

1027.  It  is  this  chance  of  escape  that  has  given  reputation  to 
all  the  remedies  of  the  prophylactic  kind  that  has  hitherto  been 
imposed  upon  the  public ;  for  from  long  observation  and  inquiry, 
we  are  satisfied  that  no  such  power  exists  in  any  nostrum  hither- 
to proposed.     Yet  this  delusion  may  be  useful  occasionally,  by 
creating  a  confidence  in  the  patient  that  he  will  escape,  and  thus 
abate  the  severity  of  mental  anguish  that  is  so  sure  to  follow  this 
accident;  therefore  these  remedies  maybe  safely  resorted  to, 
provided  they  do  not  prevent  the  use  of  such  mechanical  means 
as  have  given  security  against  this  awful  affliction. 

1028.  We  are  aware  that  Dr.  James*  has  attempted  to  prove 
that  mercury  had  a  decided  prophylactic  power — his  experiments 
were  conducted  on  a  pack  of  hounds — he  gave  them  turpeth  mi- 
neral in  pills;  and  he  declares,  that  all  the  dogs  that  were  sali- 
vated, in  whatever  stage  of  the  disease  it  might  happen,  recover- 
ed, and  the  rest  all  died.     But  unfortunately  for  mankind,  his 
experiments  upon  the  human  subject  were  not  equally  success- 
ful ;  they  amount  but  to  three,  and  each  of  these  took  the  mer- 
cury immediately  after  the  bite  as  a  preventive ;  we  must  not 
therefore  positively  depend  upon  the  agency  of  the  mercury  in 
preventing  hydrop~hobia,  because  neither  of  these  three  went 
mad;  for  as  just  stated  on  the  authority  of  Mr.  Hunter,  that  of 
twenty  bitten,  one  only  suffered.     A  variety  of  other  remedies 
have  been  proposed;  have  had  their  trial,  and  have  so  utterly 
failed,  that  the  slightest  dependence  cannot  be  placed  upon  them — 
such  has  been  the  fate  of  opium,  musk,  arsenic,  Prussic  acid, 
plantain,  chlorine,  &c.  &c.     Dr.  Good  seems  however  to  rely 
with  considerable  confidence  in  a  certain  preventive  to  dogs ; 
this  preventive  consists  in  that  morbid  condition  of  the  animal, 
commonly  called  the  dog  distemper.  The  facts  he  has  collected 

*  Philos.  Trans.  Vol.  XXXIX.  for  years  1735—6. 


310  HYDROPHOBIA- 

upon  this  subject,  are  both  too  curious  and  important,  not  to  be 
mentioned. 

1029.  "  I  ought  not,  however,  to  conclude  without  noticing 
one  very  extraordinary  fact  in  the  economy  of  morbid  poisons, 
and  especially  of  that  before  us,  which  I  have  had  confirmed  by 
the  testimony  of  several  veterinary  practitioners  entitled  to  cre- 
dit    It  is,  that  no  dog  who  has  ever  had  the  distemper,  as  it  is 
called,  which  is  the  canine  catarrh  or  influenza,  has  been  known 
to  become  rabid  spontaneously,  though  he  is  capable  of  receiving 
the  disease  by  the  bite  of  another  dog.   If  this  be  true,  for  which, 
however,  I  cannot  fully  vouch,  we  have  certainly  another  in- 
stance of  morbid  poisons  mortally  conflicting  with  each  other; 
and  it  might  be  worth  trying  how  far  inoculation  with  the  mat- 
ter of  canine  catarrh  might  succeed  in  protecting  a  human  sub- 
ject after  the  infliction  of  a  rabid  bite;  though  in  the  dog,  per- 
haps, from  a  stronger  predisposition  to  rabies,  it  seems  to  be 
impotent.     In  South  America,  rabies,  as  already  observed,  is 
altogether  unknown,  and  I  have  hence  been  anxious  to  learn 
whether  the  distemper  be  unknown  there  also;  and  in  answer  to 
this  inquiry,  it  has  been  told  me,  by  several  intelligent  residents 
in  that  quarter,  that  this  last  disorder  is  so  common  and  so  fatal, 
that  two-thirds  of  the  dogs  littered  there  perish  of  it,  while  pups; 
a  remark  which  still  further  confirms  the  home-report  concern- 
ing its  influence  on  rabies,  and  sufficiently  explains  the  non-exist- 
ence of  the  latter  on  the  shores  of  Plata." — Good's  Study  of 
Medicine,  Vol.  III.  p.  260. 

1030.  If  this  account  be  true,  it  offers  a  very  fair  means  to 
diminish  at  least  the  number  of  mad  dogs,  and  merits  a  candid 
and  impartial  trial.     But  unfortunately,  there  is  so  much  fable 
connected  with  the  history  and  cure  of  this  terrible  disease,  that 
the  practitioner  never  knows  on  what  remedies  to  rely ;  and  his 
efforts  are  reduced  to  this  unfortunate  predicament,  (as  regards 
either  the  patient  or  his  own  reputation,)  that  it  is  almost  a  mat- 
ter of  indifference,  which  plan  of  treatment  he  adopts — for  the 
patient  will  almost  certainly  die,  and  the  practitioner  will  incur 
censure,  because  some  other  mode  had  not  been  adopted — for 
every  body  undertakes  to  judge,  or  knows  of  some  infallible 
cure,  for  hydrophobia. 

1031.  Dr.  Good  informs  us,  that  Sir  Walter  Farquhar  has 
lately  received  a  communication  from  Russia,  in  which  the  mad- 
wort  plantain,  (aly sma  plantago, )  is  said  to  have  cured  the  dis- 
ease in  every  instance  for  the  last  twenty-five  years.     If  we  are 
rightly  informed,  this  plant  has  been  faithfully  tried  in  the  south, 
but  without  the  slightest  benefit.  So  with  the  skull-cap,  so  much 
vaunted  by  Mr.  Coleman — it  utterly  failed  in  every  trial,  made 
in  this  city.     In  a  word,  we  have  no  preference  for  any  plan 


HYDROPHOBIA.  311 

hitherto  proposed  ;  and  we  but  too  sorrowfully  believe,  as  far  as 
regards  the  real  interest  of  the  patient,  that  one  is  about  as  good 
as  another ;  for  each  purport  to  have,  been  successful  in  certain 
hands;  but  the  efficacy  of  all,  is  as  certainly  destroyed,  by  trans- 
mission. The  only  reliance  then,  is  to  be  placed,  upon  the  im- 
mediate, and  entire  removal  of  the  virus — either  by  surgical  ope- 
rations, or  by  long-continued  ablutions. 

1032.  This  disease  makes  its  appearance  at  very  different  pe- 
riods after  the  insertion  of  the  poison — sometimes,  in  a  few  days, 
and  other,  not  for  months  agreeably  to  some  authorities.     Upon 
this  head,  as  well  as  upon  several  others  connected  with  this  dis- 
ease, unfortunately  much  uncertainty  prevails.  We  say  unfortu- 
nately, for  so  it  is,  as  when  a  long  period  is  said  to  be  required 
to  bring  the  virus  into  action,  the  mental  sufferings  are  no  less 
constant,  than  severe.    We  have  no  faith  whatever  in  such  cases 
as  had  but  a  few  hours  to  intervene  between  the  bite,  and  the 
appearance  of  the  disease,  or  in  such  as  required  years  for  this 
accomplishment.     The  time,  from  all  we  can  collect,  will  range 
between  the  fifteenth  and  the  seventieth  day.     Authority  is  too 
vague  upon  this  head,  to  allow  us  to  believe  that  the  disease  will 
appear  earlier  than  the  time  just  specified ;  or  for  it  to  procrasti- 
nate beyond  the  limit  just  assigned — especially,  as  we  know  this 
disease  to  be  not  very  unfrequently  similated.   This  particularly 
occurs  in  habits  of  nervous  temperament,  and  in  which  the 
dread  of  water  has  been  known  to  take  place;  but  which  symp- 
tom has  too  exclusively  been  considered  the  pathognomonic 
sign  of  this  disease.     Nor  has  this  particular  symptom  always 
been  confined  to  the  nervous  subject ;  for  it  has  been  observed  in 
diseases  of  certain  organs,  and  of  a  true  inflammatory  kind — as 
in  phrenitis,  carditis,  hysteritis,  &c. 

1033.  The  cause  of  the  retardation  of  the  specific  effects  of  the 
canine  virus,  or  its  want  of  a  fixed  period  like  some  other  mor- 
bid poisons,  as  small-pox,  measles,  vaccine,  or  cow-pox,  &c.  has 
been  vaguely,  and  unsatisfactorily  accounted  for.     One  has  at- 
tempted its  explanation,  by  supposing  a  necessity  of  some  che- 
mical change  in  the  part  itself,  or  the  system  at  large,  before  the 
disease  could  appear.     Another,  by  calling  in  the  aid  of  what  is 
called  "nervous  sympathy;"  while  a  third  supposes  it  may  be 
the  habit  of  the  poison  to  lay  dormant,  until  certain  local  suscep- 
tibilities take  place,  to  rouse  it  into  action.     It  will  however  be 
readily  admitted,  that  these  several  conjectures  are  purely  hypo 
thetical,  or  at  best  the  substitution  of  one  inexplicable  phenome- 
non to  account  for  another. 

1034.  The  most  ingenious  and  best;  sustained  hypothesis  upon 
this  subject  that  we  have  met  with,  is  that  of  Mr.  Salt.*     Mr. 

*  Essay  on  the  mode  by  which  constitutional  disease  is  produced  from  the 
inoculation  of  morbid  poisons. 


312  HYDROPHOBIA. 

Salt  does  not  believe  that  direct  constitutional  effects  will  be  pro- 
duced by  the  introduction  of  a  morbid  poison  from  one  animal 
into  the  absorbent  system  of  another;  for  he  declares  it  to  be 
either  innocent  if  absorbed  in  this  state,  or  becomes  so  while 
passing  through  the  absorbents.  He  supposes  that  the  specific 
effects  upon  the  constitution  of  the  inoculated  animal  are  produced 
by  a  fluid  secreted  by  its  own  arteries,  very  similar  to  the  poison 
applied  to  them  ;  the  poison  applied,  imparting  to  the  arteries  of 
the  part  an  action  capable  of  secreting  such  a  fluid — and  conse- 
quently, agreeably  to  this,  the  virus  does  not  absolutely  lie  dor- 
mant, but  gives  an  impulse  of  greater  or  less  force  to  the  arteries 
of  the  part  wounded,  which  at  length  eventuates  in  inflammation 
and  secretion.  He  further  supposes,  that  in  cases  where  no  effect 
is  produced  by  the  morbid  poison,  it  has  been  taken  up  by  the 
absorbents,  and  thus  rendered  inert.  He  illustrates  this  point 
with  considerable  ingenuity  and  plausibility.  He  says,  that  it 
sometimes  happens,  that  of  four  persons  carefully  inoculated  from 
the  same  pustule,  two  may  take  the  disease,  and  two  may  not — 
in  the  latter  case,  he  says,  he  cannot  suppose  the  absorbents  have 
been  inactive,  but  that  the  poison  has  become  innocent  by  its 
absorption. 

1035.  He  declares,  that  the  fact  of  the  removal  of  the  part 
wounded  some  time  after  its  infliction,  proves  the  justness  of  his 
views;  for  by  this  means  you  remove  the  inflamed  part  which  is 
to  become  capable  of  multiplying  the  virus.     And  further,  that 
immediately  before  the  constitutional  symptoms  appear,  that  pain 
and  other  local  irritations  are  felt  in  the  part  originally  wounded, 
together  with  symptoms  of  pyrexia.   He  gives  a  number  of  well 
attested  instances  of  the  success  of  the  excision  of  the  wounded 
part,  even  several  days  after  the  bite,  and  where  there  could  be 
no  doubt  of  the  rabid  state  of  the  animal. 

Symptoms. 

1036.  This  disease,  like  most  others,  has  its  precursors — these 
are  both  general  and  local.    The  first  consists  of  languor,  a  sense 
of  weakness,  and  indisposition  to  motion,  or  to  mental  exertion. 
Chilliness,  nausea,  vomiting,  loss  of  appetite,  hurried  respiration, 
&c.;  in  a  word,  all  the  signs  that  constitute  pyrexia.     Sleep  is 
interrupted  and  precarious,  and  is  not  unfrequently  accompanied 
by  distressing  or  frightful  dreams ;  tremors,  starlings,  and  dart- 
ing pains,  sometimes  from  the  wounded  part  to  the  head  or  the 
stomach.    The  temper  becomes  irritable,  and  illy  brooks  contra- 
diction; while  confidence  of  every  kind  is  diminished,  and  the 
patient  becomes  the  prey  of  gloomy  anticipations.    The  venereal 
appetite  in  the  male  is  sometimes  highly  excited ;  so  much  so  in 
one  instance  that  we  witnessed,  that  an  almost  constant  priapism 


HYDROPHOBIA.  313 

was  present.  These  anticipating  symptoms  are  generally  of  some 
days  continuance.  The  local  symptoms  are  rarely  severe,  or  for 
the  most  part,  not  more  severe  than  a  wound  of  the  same  extent 
inflicted  by  the  same  weapon,  by  a  sound  animal.  The  wound  ge- 
nerally heals  without  difficulty,  and  this  for  the  most  part  lulls  the 
patient  into  a  false  security,  as  this  circumstance  does  not  inter- 
rupt the  onset  of  the  constitutional  symptoms — on  the  contrary 
indeed,  where  suppuration  has  taken  place  in  the  part,  the  pa- 
tient has  been  known  to  escape  this  direful  disease. 

1037.  The  healing  of  the  wound  however  is  the  more  com- 
mon  event;  and  the  part  will  keep  free  from  suffering  for  an  un- 
certain period.     But  just  before  the  constitutional  symptoms 
show  themselves,  the  wounded  part  is  generally,  or  perhaps  al- 
ways, found  to  become  tender,  to  be  more  or  less  inflamed,  the 
progress  of  which  is.  marked  by  the  course  of  the  absorbents,  and 
it  is  at  this  time  that  the  system  may  be  found  to  labour  under 
febrile  phenomena.     It  however  rarely  happens  that  the  wound- 
ed parts  ulcerates,  or  that  a  fluid  is  formed  ;  yet  such  instances 
have  occurred. 

1038.  Mr.  Salt  says  upon  the  occurrence  of  these  changes, 
(f  it  appears  to  me  that  the  pain  felt  distinctly  in  the  part  at  this 
period,  accompanied  by  shivering,  and  sometimes  by  diseased, 
change  of  structure,  are  sufficient  evidence  that  the  poison  finds 
its  way  into  the  constitution,  under  the  controul  of  the  general 
law,  which  I  have  presumed  regulates  the  introduction  of  other 
morbid  poisons.     It  is  not  necessary  that  a  very  distinct  and  co-t 
pious  secretion  should  take  place;  for  certainly  the  absorption  of 
a  very  minute  portion  of  secreted  fluid  is  sufficient  to  occasion 
all  the  constitutional  effects  as  is  demonstrated  in  the  production 
of  syphilis ;  nor  is  it  essential  that  the  secreted  fluid  should  pos- 
sess a  puriform  appearance,  when  we  know  that  the  secretion  in 
the  pustule  of  the  vaccine  virus,  in  its  most  active  state,  differs 
little  in  appearance  from  a  drop  of  clear  water."  p.  52. 

1039.  The  premonitory  symptoms  usually  precede  the  con- 
firmed constitutional  symptoms  about  eight  or  ten  days.     And 
one  of  the  most  constant  of  these  is  the  aversion  from  water,  or 
from  any  surface  that  can  give  the  idea  of  this  fluid — antl  hence 
the  name  of  the  disease.     Instances  nevertheless  have  occurred, 
especially  in  dogs,  in  which  this  symptom  was  either  not  con- 
stantly present,  or  not  strongly  marked,  or  altogether  wanting. 
We  once  witnessed  a  case  with  the  late  Dr.  Bensel  of  German- 
town,  in  which  the  patient  swallowed  at  one  draft,  nearly  a  tum- 
blerful of  water  a  few  hours   before  he   died.      Yet  at  other 
times  the  utmost  distress,  nay  agony,  is  produced  by  the  presence 
of  water,  or  even  by  the  presence  of  any  thing  with  which  the 
idea  of  water  can  be  associated.    It  has  however  appeared  to  us, 

40 


314  HYDROPHOBIA. 

that  this  dread  is  owing  rather  to  the  extreme  desire  for  this 
fluid  throwing  the  whole  apparatus  connected  with  swallowing 
into  violent  and  highly  painful  spasm,  than  to  an  extreme  aver- 
sion to  the  water  itself — for  the  patient  who  swallowed  the 
tumblerful  of  water  a  short  time  before  his  death,  informed  us 
that  his  thirst  was  extreme,  but  dared  not  always  attempt  in- 
dulging it,  from  the  pain  excited  in  his  throat  at  certain  times — 
but  in  this  instance  even,  the  effort  to  swallow  was  an  extreme 
effort.  We  have  already  remarked  that  symptom  was  not  pa- 
thognomonic,  as  it  has  appeared  in  other  diseases. 

1040.  There  is  a  profuse  secretion  of  saliva,  which  the  patient, 
almost  as  constantly  as  it  is  formed,  ejects  from  his  mouth  with 
great  force  and  uncertain  direction — we  never  saw  one  use  a  ves- 
sel to  spit  in,  or  employ  a  cloth  for  this  purpose.     During  the 
progress  of  the  disease,  the  violence  of  symptoms  occasionally 
suffer  abatement — but  this  is  transitory,  and  even  unsatisfactory, 
as  the  succeeding  paroxysm  seems  to  be  the  more  severe,  by 
even  this  temporary  truce.     There  is  considerable  difference  in 
the  character  of  the  disease  as  far  as  we  have  seen — that  is,  some 
are  much  more  vehement  and  ferocious  than  others  during  the 
paroxysms;  some  exhibiting  all   the  violence  of  the  maniac; 
others  exhibit  a  kind  of  mild  delirium  ;  while  others  are  calm 
and  resigned. 

1041.  The  paroxysms  differ  not  only  in  intensity,  but  in  du- 
ration— some  will  continue  half  an  hour,  while  others  will  occu- 
py but  a  few  minutes.     Nor  does  the  patient  become  maniacal, 
strictly  speaking,  as  we  have  seen  two  or  three  instances  in 
which  they  preserved  their  senses  as  in  tetanus,  to  the  last  mo- 
ment.    This  was  the   case   in   Dr.  Bensel's  patient   mentioned 
above ;  also  in  Mr.  Thompson's  boy,  that  was  attended  by  Drs. 
Rush,  Physick  and  myself.  The  patient  is  averse  to  lying  down 
in  most  cases — they  greatly  prefer  sitting  up;  and  still  more,  if 
not  too  much  weakened,  walking  about. 

1042.  The  pulse  is  not  much  disturbed  in  this  disease,  though 
it  pretty  constantly  betrays  febrile  irritation,  especially  towards 
the  close  of  the  disease,  when   it  becomes  extremely  frequent. 
The  bowels  are  generally  constipated;  the  urine  scarce;  the  skin 
dry  and  husky,  or  bedewed  with  a  cold  exudation;  the  tongue 
dry,  sometimes  chapped  and  hard.     Light  is  generally  offensive 
to  the  eyes,  and  the  hearing  is  sometimes  extremely  acute.   The 
duration  of  the  disease  is  rarely  beyond  the  sixth  day. 

Pathology. 

1043.  It  seems  that  post  mortem  examinations  have  thrown  but 
little  light  upon  the  changes  produced  in  any  one  part  of  the  body 


HYDROPHOBIA.  315 

by  this  disease.  Indeed  the  appearances  recorded  by  authors, 
are  extremely  different  from  each  other,  and  as  altogether  unsa- 
tisfactory. The  brain  seems  however  to  suffer  principally;  vas- 
cular congestions  are  pretty  constantly  observed  both  in  its  sub- 
stance and  in  its  meninges ;  effusions  in  its  ventricles,  and  the 
cervical  ganglia  have  been  found  engorged  and  inflamed.  The 
mouth,  fauces,  glottis,  and  trachea  are  inflamed  to  some  extent 
for  the  most  part,  but  not  constantly.  The  lungs  are  usually 
filled  with  blood,  and  its  mucous  membrane  inflamed.  Some- 
times traces  of  inflammation  are  found  in  the  stomach  and  intes- 
tines. And  it  is  asserted  by  some,  that  the  nerves  leading  from, 
the  wounded  part  have  been  found  inflamed  to  a  considerable 
extent.  Mr.  Salt  is  of  opinion  however,  that  the  changes  pro- 
duced in  the  bitten  part  have  been  too  much  neglected  by  pa- 
thologists;  as  it  would  seem  from  all  testimony,  that  previously  to 
the  appearance  of  the  constitutional  symptoms,  uneasiness  is  al- 
ways felt  in  the  part  that  originally  received  the  virus.  It  is  on 
this  account  that  this  author  draws  the  conclusion,  that  the  con- 
stitutional symptoms  are  not  the  result  of  the  absorption  of  the 
virus ;  as  these  do  not  take  place  but  after  a  considerable  lapse 
of  time,  from  the  infliction  of  the  wound  and  the  deposition  of 
the  poison,  "a  delay  which  would  probably  not  occur  if  it  were 
subjected  to  the  operation  of  direct  absorption  only."  p.  57. 

1044.  This  view  of  the  subject  merits  more  attention  per- 
haps than  has  hitherto  been  bestowed  upon  it ;  especially  as  the 
local  symptoms  invariably  precede  the  constitutional  disturb- 
ances. 

Treatment. 

1045.  Of  the  treatment  of  hydrophobia,  what  shall  we  say  that 
will  excite  to  exertion  or  that  will  merit  confidence  ?  For  if  we 
are  honest,  we  must  confess,  that  neither  ingenuity  nor  industry, 
has  so  far,  ever  been  rewarded  by  a  cure.     Shall  we  incur  cen- 
sure by  this  excluding  opinion,  and  be  told,  that  the  records  of 
medicine  furnish   many   examples    of  cures  of  hydrophobia ; 
and  that  we  are  opposing  single-handed,  the  testimony  of  a 
host  of  respectable   authority?    But  let  us  not   be  supposed, 
when  we  declare  it  as  our  decided  opinion,  that  a  genuine  case 
of  hydrophobia  has  never  been  cured,  that  we  are   doubting 
the  truth  of  these  authorities.     For  we  freely  admit  that  some 
have  recovered  from  this  terrible  disease;  but,  that  the  recove- 
ries were  owing  to  any  plan  of  treatment,  we  utterly  disbelieve—  / 
for  we  know  that  nature  now  and   then  triumphs  over  art  in  < 
some  of  the  most  deplorable  instances  of  disease;  and  these  vie-  i 
tories  of  the  recuperative  powers  of  the  system  are  benevolently 


316  HYDKOI'HOBIA. 

set  down  to  the  credit  of  the  medical  art.)  We  therefore  unhe- 
sitatingly declare,  that  up  to  this  time  no  one  plan  of  the  many 
that  have  been  proposed  merits  the  slightest  preference  over  any 
other;  and  though  it  is  but  natural  and  human  to  hope,  that  this 
terrible  malady  will  sooner  or  later  be  stricken  from  the  oprobia 
medicorum,  it  is  nevertheless  but  honest  to  confess  that  it  is  yet 
to  be  numbered  among  them. 

1046.  Upon  a  review  of  what  has  been  said  of  the  powers  of 
certain  articles  of  the  materia  medica  in  this  disease,  we  should 
be  more  disposed  to  place  reliance  upon  mercury  than  upon  any 
other  remedy  ;  but  for  even  this  to  be  possibly  useful,  it  must 
be  employed  in  very  liberal  doses,  both  internally  and  exter- 
nally; and  this  with  the  most  unremitting  industry.     And  until 
further  testimony  in  favour  of  the  efficacy  or  utility  of  cold  and 
warm  bathing,  drowning,  the  belladonna,  the  plantain,  vinegar, 
the  skull-cap,  &c.  &c.  can  be  produced,  we  would  consign  them 
"  to  the  tomb  of  all  the  capulets." 

1047.  But  in  this  proscription,  we  do  not  include  the  local 
treatment  of  the  bitten  part — for  upon  this  depends  the  only 
chance  of  escape  from  this  frightful  malady.     We  are  sorry  to 
find,  however,  that  precautionary  measures  have  been,  and  con- 
tinue to  be,  so  exclusively  limited  to  internal  remedies  or  pro- 
phylactics; while  the  more  obvious  and  rational,  are  so  constantly 
neglected.     The  most  certain  plan  consists  in  the  removal  of  the 
virus  from  the  wounded  part,  and  this  as  effectually,  and  as 
speedily,  as  possible.     The  local  treatment  will  consist  in  the 
only  three  modes  that  we  possess  to  fulfil  this  indication— name- 
ly, ablutions  and  excision ;  and  we  may  add,  the  actual  cautery. 

1048.  Jlblutions,  we  are  convinced,  would  always  succeed, 
if  they  were  promptly  employed  and  industriously  pursued,  in 
cases  proper  for  their  operation — for  all  cases  should  not  be 
trusted  to  them.     The  cases  proper  for  ablutions,  are  such  as 
have  the  skin  but  slightly  grazed,  or  those  in  which  the  wound 
is  clean  and  very  superficial.    In  both  of  these  kinds  of  wounds, 
the  whole  surface  of  the  sore  can  be  commanded ;  they  should 
therefore  be  carefully  washed  by  a  sponge  or  piece  of  flannel  with 
lukewarm  soap-suds  teemed  from  a  tea-kettle;  for  the  water 
that  has  once  passed  over  the  wound  should  not  again  be  applied, 
lest  even  the  much  diluted  virus  be  capable  of  doing  mischief. 
This  should  be  continued  for  at  least  an  hour;  or  longer,  if  it  be 
the  wish  of  the  patient  or  his  friends;  and  it  may  be  repeated  in 
a  more  gentle  manner  from  time  to  time,  during  the  first  twenty- 
four  hours.  We  believe,  from  its  success  in  the  case  we  witnessed, 
and  as  related  above,  that  this  will  give  every  necessary  securi- 
ty— but  this  plan  we  must  repeat,  should  be  confined  to  wounds 
of  the  nature  just  described. 


HYDROPHOBIA.  317 

1049.  Excision. — This  operation  should  always  be  had  re- 
course to,  when  the  tooth  of  the  animal  has  penetrated  even  but 
a  little  way  below  the  surface  of  the  skin;  but  the  wound  should 
be  washed  as  above  directed,  until  an  operator  can  be  procured. 
In  performing  this  operation,  the  surgeon  should  not  be  too  spar- 
ing of  his  patient's  flesh,  as  his  security  may  depend  upon  the 
extent  of  the  excision.     When  the  wound  has  penetrated  among 
the  bones  of  the  hand  or  the  foot,  amputation  has  been  recom- 
mended.    Some  prefer  the  destruction  of  the  part  by  the  actual 
cautery,  and  this  might  be  the  preferable  mode  of  operating, 
when  delay  has  occurred,  as  the  size  of  the  eschar  can  easily  be 
commanded.     Nor  should  we  be  deterred  from  either  of  these 
operations  because  a  considerable  time  has  intervened.     For  Dr. 
Babington*  mentions  several  cases  in  which  it  proved  successful 
after  considerable  delay.     One  in  which  twenty-four  hours  had 
elapsed.     Two  other  cases,  one  of  twenty-three  hours  standing, 
the  other  sixty-eight  hours.     Another  of  thirty  hours  interval ; 
another  of  twenty-eight  days;  another  of  three  days.     "  Seven 
persons  were  bitten  by  rabid  dogs  about  the  same  time.     Three 
did  not  apply  until  the  third  day;  two  on  the  second  day;  two 
not  till  some  time,  (the  time  not  specified,)  after  the  accident ; 
the  parts  were  then  extirpated,  and  they  all  did  well.     A  foal 
was  treated  in  the  same  way,  bitten  five  days  before ;  the  animal 
continued  well  a  long  time  after.     On  the  other  hand,  the  same 
dog  bit  a  horse,  a  cow,  and  two  pigs  on  the  same  day  ;  no  exci- 
sion was  used;  and  though  internal  remedies  were  administered, 
the  animals  were  all  dead  within  a  month ;  a  presumptive  proof 
of  the  superiority  of  extirpation.  Two  other  patients,  father  and 
son,  were  bitten,  the  parts  removed  about  forty  hours  after  the 
bite."t     All  these  operations  succeeded  completely. 

1050.  We  cannot  place  reliance  upon  the  ligature,  as  warmly 
recommended  by  Dr.  Good — first,  because,  if  the  disease  be  pro- 
duced by  absorption,  the  ligature  only  prevents  its  progress  as 
long  as  it  is  applied,  if  reliance  can  be  placed  upon  the  experi- 
ments of  Dr.  Pennock.     Secondly,  it  prevents  ablutions  or  ex- 
cision from  being  practised;  or  at  least  he  does  not  recommend 
either  at  the  same  time.     Thirdly,  a  ligature  cannot  always  be 
applied.     Fourthly,  because  we  do  not  believe  that  the  disease 
is  caused  by  the  absorption  of  the  virus. 

*  Medical  Researches  for  1798,  p.  134.          f  Hamilton  on  Hydrophobia. 


318  DISEASES    OF    THE    EYES. 

CHAPTER  IX. 

DISEASES  OF  THE  EYES. 
General  Observations. 

1051.  THE  diseases  of  the  eyes  and  their  appendages,  the 
brows,  lids,  and  lachrymal  organs  and  passages — form  a  class  of 
affections  so  numerous,  diversified  and  important,  as  to  consti- 
tute in  many  parts  of  Europe,  a  separate  branch  of  study  and 
practice;  and  in  the  principal  universities,  their  consideration  is 
the  province  of  an  appropriate  professorship.    It  will  not,  there- 
fore, be  expected  in  a  treatise  on  the  practice  of  physic,  that  we 
should  enter  into  a  particular  investigation  of  these  complaints; 
for  even  if  they  be  not  considered  as  belonging  to  a  distinct  divi- 
sion of  our  art,  at  least  many  of  them  appertain  rather  to  the 
province  of  surgery  than  to  that  of  physic ;  and  moreover,  to 
treat  of  them  in  detail  would  require  more  space  than  we  can 
with  any  propriety  allot  to  that  purpose.      All  that  we  shall  at- 
tempt, will  be,  to  give  a  general  and  cursory  sketch  of  the  more 
prevalent  and  important  derangements,  or  those  which  the  me- 
dical practitioner  is  most  frequently  called  upon  to  treat;  re- 
ferring those  who  desire  more  particular  information  to  the  pro- 
fessed works  on  the  subject. 

1052.  Several  distinct  structures  enter  into  the  formation  of 
the  eye,  some  of  which  are  entirely  different  from  any  of  the 
other  tissues  of  the  body.     The  conjunctiva,  or  the  membrane 
which  lines  the  eyelids,  and  covers  the  anterior  half  of  the  globe 
of  the  eye,  though  villi  cannot  be  seen  on  its  free  surface,  may 
be  considered  as  a  mucous  membrane,  except  that  portion  cover- 
ing the  cornea,  which  exhibits  a  nearer  approach  to  the  character 
of  serous  than  to  that  of  mucous  tissues.     The  sclerotica  is  a 
fibrous  tissue,  except  its  anterior  transparent  portion,  the  cornea, 
which  cannot  with  propriety  be  arranged  in  this  class.*     The 
membrane  lining  the  chambers  of  the  eye,  and  covering  the 
iris — called  the  membrane  of  the  aqueous  humour — the  choroid 
and  hyaloid  membranes,  may  perhaps  without  any  great  error 
be  considered  as  serous  tissues.   The  retina  is  a  nervous,  and  the 

•  Professor  Mayer,  of  Bonn,  in  his  classification  of  the  organic  tissues,  places 
the  cornea,  crystalline  lens,  epidermis,  hair,  nails,  teeth,  &c.  in  a  class  to  which 
he  has  given  the  name  of  Lamellar.  It  may  be  objected  to  this  arrangement, 
that  the  structures  he  has  thus  grouped  together  differ  as  much  from  one  an- 
other as  they  do  from  those  with  which  they  were  formerly  arranged. 


DISEASES   OP    THE    EYES.  319 

iris  an  erectile  tissue.     The  cornea  and  crystalline  lens*  differ 
from  any  other  portions  of  the  body  in  their  structure. 

1053.  These  tissues  are  all  liable  to  inflammation,  which  not 
only  varies  in  violence,  but  presents  a  peculiar  character  in  each 
class,  and  which  even  in  the  same  class  is  modified  by  peculiari- 
ties of  constitution  in  the  patient.   These  variations  have  afforded 
to  the  nosologists  an  opportunity  for  the  manufacture  of  species, 
and  the  construction  of  a  nomenclature,  of  which  they  have  not 
been  neglectful;  and  accordingly  we  have  a  host  of  names,  an 
enumeration  of  which  we  will  spare  the  reader. 

SECT.  I.  CONJUNCTIVITIS. — INFLAMMATION  OP  THE  CON- 
JUNCTIVA. 

Anatomical  Characters  of  the  Conjunctiva. 

1054.  The  conjunctiva  is  the  most  delicate  of  all  the  mucous 
membranes;  it  is  exceedingly  thin,  transparent,  devoid  of  pa- 
pillae, colourless  upon  the  globe,  and  of  a  rose  colour  upon  the 
eyelids.     That  portion  which  covers  the  cornea  is  united  to  its 
subjacent  coat  so  closely,  that  it  is  difficult  to  separate  them.  To 
the  sclerotica  and  eyelids,  it  is  loosely  connected  by  a  fine,  cel- 
lular tissue;  within  which,  between  the  conjunctiva  and  the  car- 
tilages of  the  palpebras,  are  a  number  of  small  whitish  or  yel- 
lowish glands,  consisting  of  minute,  very  elongated,  narrow, 
tortuous  sacs,  which  pour  out  their  secretions  through  small  open- 
ings, disposed  in  a  regular  arcuated  line,  just  within  the  edge  of 
the  eyelids. 

Physiological  Characters. 

1055.  The  conjunctiva,  in  a  healthy  state,  secretes  a  mucous 
fluid,  which  is  liable  to  be  increased,  altered,  or  suppressed  by 
inflammation.     It  possesses  a  high  degree  of  sensibility. 

Pathological  Characters. 

1056.  The  susceptibility  of  parts  to  inflammation,  the  conti- 
nuance and  violence  of  the  affection,  and  the  facility  with  which 
restoration  takes  place,  appear  to  be  in  direct  proportion  to  the 
facility  with  which  their  vessels  can  be  distended.     From  the 
looseness  with  which  the  conjunctiva  is  connected  with  the  pal- 
pebrae  and  sclerotica,  their  vessels  readily  expand  so  as  to  admit 
red  blood,  and  when  the  exciting  cause  is  removed,  unless  the 

*  .T'16  aclueous  and  vitreous  humours,  though  important  parts  of  the  organ 
of  vision,  cannot  be  considered  as  organic  tissues — when  they  become  morbid, 
it  is  the  result  of  disease  in  the  vessels  by  which  they  are  secreted. 


320  DISEASES    OF    THE    EYES. 

disease  has  been  of  very  long  duration,  as  speedily  recover  their 
tone,  and  contract  to  their  original  dimensions.  Very  different, 
however,  is  the  case  with  respect  to  the  corneal  conjunctiva;  it 
is  united  to  the  cornea  by  such  a  dense  connecting  texture,  that 
its  vessels  are  prevented  enlarging  themselves  even  during  high 
degrees  of  inflammation,  and  red  blood  is  only  admitted  into 
them  when  the  inflammation  is  long-continued;  but  when  once 
distended,  their  restoration  is  very  difficult,  and  seldom  effected 
without  some  derangement  in  structure  and  loss  of  transparency 
in  the  part. 

1057.  Inflammation  of  the  conjunctiva  commences  by  dilata- 
tion of  its  white  capillaries  or  serous  vessels,  which  in  a  healthy 
state  are  not  visible,  but  may  now  be  seen  conveying  red  blood, 
and  as  the  disease  advances,  the  number  of  these  red  vessels  in- 
creases; the  sensibility  of  this  membrane  is  exalted,  and  villi 
usually  become  apparent.     The  natural  secretion  is  increased, 
afterwards  altered,  and  finally  pus  is  poured  out,  often  very  pro- 
fusely.    In  some  rare  instances  coagulable  lymph  is  secreted, 
completely  agglutinating  the  occular  and  palpebral  conjunctiva; 
one  case  of  this  we  have  seen.     A  serous  fluid  and  sometimes 
blood  is  effused  in  the  cellular  tissue  beneath  the  conjunctiva. 
In  the  progress  of  the  disease,  coagulable  lympth  is  effused  in 
the  substance  of  the  conjunctiva ;  this  membrane  becomes  thick- 
ened, hardened,  and  sometimes  on  the  globe  assumes  the  appear- 
ance of  tendon.     Among  the  consequences  of  inflammation,  may 
be  noted  an  excessive  and  morbid  condition  of  the  nutritive  ac- 
tions, occasioning  fungous  excrescences,  especially  near  the  edge 
of  the  tarsi,  which  are  sometimes  of  a  fleshy  appearance,  at  others 
of  a  hard  cartilaginous  nature  resembling  warts,  and  not  unfre- 
quently  of  a  soft,  spongy  texture,  and  dark  colour,  resembling 
clots  of  blood. 

1058.  Inflammation  does  not  readily  extend  to  the  corneal 
conjunctiva,  but  in  severe  inflammation  of  the  eye  it  becomes 
eventually  affected.     This  is  first  manifested  by  a  slight  haze  or 
dimness  produced  by  a  fulness  of  its  serous  vessels;  these  in  the 
progress  of  the  disease  become  so  dilated  as  to  convey  red  blood; 
coagulable  lymph  is  thrown  out,  thickening  this  membrane,  and 
rendering  it  opaque.     The  conjunctiva  has  little  disposition  to 
ulcerate ;  when  ulceration  occurs,  it  is  usually  the  consequence 
of  pustules  or  small  abscesses  beneath  it. 

1059.  When  inflammation  is  kept  up  for  a  length  of  time,  in 
the  sclerotic  conjunctiva,  its  blood-vessels  become  permanently 
enlarged,  coagulable  lymph  is  secreted  around  them,  and  a  mem- 
brane is  formed,  which  sometimes  appears  of  a  fleshy  consist- 
ence,* at  others  like  a  delicate  tissue  of  vessels.!   Baron  Larrey 

*  Pannus  of  authors.  f  Pterygium.  • 


DISEASES    OF    THE    EYES.  321 

says  that  pterygium  was  one  of  the  most  frequent  sequelae  of 
Egyptian  ophthalmia. 

1060.  A  nodule  of  fatty  matter  is  sometimes  formed  under  the 
conjunctiva,  by  some  derangement  in  the  nutrition  of  the  part 
resulting  from  chronic  inflammation.    We  have  seen  small. hard 
bodies,  perfectly  transparent,  in  or  upon  the  sclerotic  conjunc- 
tiva, and  which  were  probably  the  effect  of  a  similar  cause. 

1061.  Sometimes  tumours  form  on  the  conjunctiva,  composed 
of  a  group  of  varicose  veins;  we  have  observed  these  only  at  the 
inner  canthus. 

Causes. 

1062.  Inflammation  of  the  conjunctiva,  may  be  excited  by  a 
variety  of  internal  as  well  as  external  causes;  among  the  former 
may  be  mentioned,  the  abuse  of  stimulating  liquors  or  food,  pro- 
longed irritation  of  the  stomach  or  alimentary  canal,  the  sup- 
pression of  perspiration,  of  the  menstrual  or  haemorrhoidal  dis- 
charge, of  a  periodical  or  chronic  haemorrhage,  or  of  an  habitual 
sweat,  metastasis  of  gonorrhoea,  the  retrocession  of  an  exanthe- 
matous  eruption,  &c.    To  the  latter  may  be  referred  foreign  bo- 
dies introduced  into  the  eye,  and  these  may  excite  irritation 
either  by  their  mechanical  operation,  as  sand,  spiculae  of  iron, 
&c.  or  by  their  corrosive  or  stimulating  properties  as  lime,  and 
different  chemical  agents,  smoke,  irritating  vapours,  &c. 

1063.  In  children  it  is  sometimes  produced  by  the  irritation  of 
teething ;  and  Mr.  Ware  says  that  he  has  seen  it  produced  in  old 
persons,  by  a  decayed  tooth. 

1064.  It  may  also  be  produced  by  any  cause  which  determines 
an  unusual  quantity  of  blood  to  the  conjunctiva ;  or  by  tight 
ligatures  around  the  neck  interrupting  the  flow  of  venous  blood 
from  the  head,  as  tight  cravats.   The  tight  inelastic  stocks  worn 
by  soldiers  was  one  of  the  causes  of  the  conjunctivitis  that  pre- 
vailed so  extensively  in  the  army  of  the  low  countries  a  few 
years  since.*     Light,  also,  either  direct,  or  reflected  from  white 
or  polished  substances,  produces  a  determination  of  blood  to  the 
eye,  and  thus  excites  inflammation  of  the  conjunctiva.  In  the  dif- 
ferent towns  upon  the  coast  of  B.arbary,  subject  to  the  Emperor 
of  Morocco,  where  it  is  the  practice  to  whitewash  the  walls  of 
the  houses  externally,  the  inhabitants  suffer  greatly-  from  this 
disease,  while  on  the  opposite  shores,  where  this  practice  does 
not  prevail,  the  inhabitants  are  exempt  from  it. 

•  Vleminckx  and  Van  Mons.  Essai  sur  1'ophthalmie  de  1'armfce  des  Pays— 

Bas.  p.  41. 

v  -          •-  •  i  -  .'*r!f-,i 

41 


322  DISEASES    OF    THE    EYES. 

1065.  Heat,   by   its  direct  stimulus,   excites  inflammation. 
Blacksmiths,  and  those  engaged  in  furnaces,  suffer  from  the  dis- 
ease occasioned  by  this  cause. 

1066.  Cold  acting  either  directly  on  the  eye,  or  through  the 
medium  of  the  constitution,  is  a  very  frequent  cause  of  the  dis- 
ease, but  it  is  sudden  transitions  from  heat  to  cold,  that  is  the 
most  prolific  source  of  the  complaint.     Soldiers  on  duty,  in  high 
latitudes,  alternately  exposed  to  the  heat  of  the  day  and  bright 
light  of  the  sun,  and  to  the  cold  and  dews  of  the  night  are  often 
seized  with  it.     In  the  commencement  of  August,  1812,  great 
numbers  of  the  French  army,  in  its  march  upon  Smolensk,  were 
affected  with  ophthalmia,  produced  by  these  causes;  and  the  Prus- 
sian corps  cParmie,  in  1813,  and  many  regiments  of  the  British 
army  in   1815,  suffered  from  the  disease,  arising  from  similar 
causes.    The  effects  of  cold  are  also  very  severe  when  combined 
with  a  current  of  wind.     Dr.   Smith  states  that  of  two  detach- 
ments of  invalids  sent  from  the  Mediterranean,  most  of  them 
were  attacked  with  inflammation  of  the  eyes  upon  reaching  the 
windy  latitudes  of  England.  Mr.  Reilly,*  surgeon  to  the  British 
ship  Saturn,  states  that  when  off  Brest,  in  October,  1797,  when 
the  weather  was  damp  and  the  wind  east,  ophthalmia  broke  out 
among  the  crew,  three  hundred  of  whom  were  attacked  with  it, 
and  he  remarks  that  the  sick  list  varied  with  the  weather.     Sol- 
diers on  guard,  during  a  stormy  night,  and  individuals  lying  op- 
posite to  open  doors  or  windows,  are  exceedingly  liable  to  be- 
come affected  with  the  disease  under  consideration.     In  France, 
during  the  conscription,  it  was  not  uncommon  for  the  young 
men  to  procure  an  habitual  ophthalmia  by  exposing  their  eyes  to 
a  current  of  air  from  a  key-hole  or  crack,  and  thus  obtain  a  dis- 
charge, for  which  they  often  paid  with  the  loss  of  an  eye.t 

1067.  Moisture  exercises  a  very  baneful  influence  over  this  af- 
fection.    Dr.  Vetch  states  that  there  was  not  a  single  case  of  the 
disease,  in  the  54th  regiment,  (in  which  it  prevailed,)  of  a  violent 
form  until  the  24th  of  September,  when  after  a  very  heavy  fall 
of  rain  during  the  night,  to  which  the  men  affected  with  the 
ophthalmia  were  more  particularly  exposed,  by  being  at  the 
time  under  canvass,  the  whole  number  of  patients,  thirty-four, 
were  found  in  the  morning  with  their  eyes  completely  closed  by 
the  swelling  of  the  palpebras,  attended  with  the  excruciating  pain, 
the  purulency,  and  other  symptoms  of  the  disease  in  its  most 
alarming  and    inveterate  form.     He  further  remarks,  that  the 
changes  in  the  state  of  the  disease  were  uniformly  influenced  by 
those  of  the  weather,  and  afforded  the  most  unequivocal  proofs 

*  Trotter's  Medicina  Nautica.  f  Dictionaire  des  Sciences  M^dicales. 


DISEASES   OF    THE    EYES.  323 

of  the  deleterious  consequences  which  result  from  an  increased 
humidity  of  the  atmosphere.  He  adds,  "  the  disease  is  so  fre- 
quently aggravated  in  wet  or  foggy  weather  as  to  attract  the  at- 
tention of  every  person  connected  with  it.'?* 

1068.  In  Egypt,  where  the  days  are  generally  hot,  and  the 
nights  cold  and  damp,  the  disease  prevails  to  an  enormous  ex- 
tent; and  we  can  readily  understand  why  inflammation  of  the 
conjunctiva  is  produced  more  frequently  than  gastro-enteritis, 
since  the  former  membrane  is  kept  in  a  constant  state  of  irrita- 
bility by  the  excessive  heat  of  the  days,  by  the  bright  light  re- 
flected from  the  sands  of  the  desert,  and  by  the  dust  with  which 
the  atmosphere  is  constantly  loaded. 

1069.  Whenever  a  great  number  of  persons  are  crowded  to- 
gether for  any  length  of  time  in  close,  ill-ventilated  apartments, 
disease  is  almost  invariably  generated;  in  some  instances  we  have 
inflammation  of  the  conjunctiva;  in  others,  inflammation  of  the 
other  mucous  membranes,  dysentery,  fevers,  &c.     In  what  pre- 
cise manner  the  impure  air  of  these  situations  acts,  we  are  not 
prepared  to  show;  that,  especially  where  the  eye  is  previously 
in  a  state  of  excitability,  the  disease  is  often  excited  by  the  dif- 
ference of  temperature  experienced  in  removing  from  the  air  of 
these  places,  heated  during  the  night,  to  the  cool  air  of  the 
morning,  we  think  no  doubt  can  exist;  but  the  impurity  of  the 
air  seems  also  to  affect  the  conjunctiva,  and  certainly  when  this 
organ  is  inflamed,  it  aggravates  the  disease.     When  the  eyes 
are  predisposed  to  inflammation,  remaining  long  in  a  crowded 
room,  is  exceedingly  prejudicial.     In  several  divisions  of  the 
British  army,  in  which  puriform  inflammation  of  the  conjunctiva 
prevailed,  the  disease  disappeared  on  their  being  sent  to  the  Pe- 
ninsula and  employed  in  active  service.     On  their  return  they 
were  placed  in  barracks,  and  in  six  months  the  disease  again  be- 
came prevalent,  and  was  again  arrested  on  the  troops  being  sent 
into  service,  t 

1070.  Soldiers  in  barracks  suffer  much  from  ophthalmia.  The 
eyes  of  this  class  of  persons  are  generally  kept  in  a  state  of  irri- 
tation by  the  light  of  the  sun,  the  dust  to  which  they  are  exposed 
during  their  long  and  frequent  drills,  and  the  conjunctiva  is  often 
injected  with  an  undue  portion  of  blood  in  consequence  of  the 
return  of  that  fluid  from  the  head  being  retarded  by  their  stiff 
collars  and  tight  dress.     With  their  eyes  in  this  state  they  are 
crowded  together  at  night  in  barracks,  the  atmosphere  of  which 
becomes  impure  and  heated,  and  at  sunrise  they  are  obliged  to 
leave  their  heated  quarters  and  expose  themselves  to  the  cold 

*  Edinburgh  Medical  and  Surgical  Journal. 

f  Vetch.  A  Practical  Treatise  on  the  Disease  of  the  Eye,  p.  188. 


324  DISEASES    OF    THE  EYES. 

air  of  the  morning,  and  are  thus  exposed  to  a  difference  of  tem- 
perature equal  to  that  between  the  day  and  night  of  tropical  cli- 
mates. 

1071.  Inflammation  of  the  conjunctiva  is  likewise  of  frequent 
occurrence  in  ships,  and  children's  asylums.    In  1782,  a  violent 
form  of  the  disease  broke  out  on  board  the  English  ship  of  war 
Albemarle,  and  in  1797,  in  one  of  the  ships  of  the  squadron  off 
Brest.   In  one  instance  it  appeared  on  board  a  French  slave  ship, 
where  it  deprived  many  of  these  unfortunate  people  of  vision, 
and  spread  so  extensively  among  the  crew,  that  only  one  of  them 
was  left  with  sight  to  bring  the  ship  to  Guadaloupe. 

1072.  In  the  Hospital  for  Children  at  Paris,  this  affection  pre- 
vails almost  constantly;  it  is  also  of  frequent  occurrence  in  the 
Foundling  Hospital  of  Bruxelles.  In  1804,  it  made  its  appearance 
in  the  Royal  Military  Asylum,  near  London,  for  the  children  of 
soldiers,  and  spread  with  such  rapidity,  that  from  April  to  the 
end  of  the  year,  three  hundred  and  ninety-two  children  were 
attacked  with  it;  it  also  appeared  in  the  spring  and  autumn  of 
several  succeeding  years.  In  the  Children's  Asylum  of  Philadel- 
phia, under  the  care  of  the  guardians  of  the  poor,  the  disease 
prevailed  for  several  years,  and  often  to  a  distressing  extent. 

1073.  New-born  children  are  very  subject  to  purulent  ophthal- 
mia. This  is  sometimes  produced  by  vicissitudes  of  temperature, 
exposure  of  the  head  to  cold,  and  perhaps  soon  after  to  the  heat 
and  light  of  large  fires,  the  use  of  dirty  sponges  to  the  face  and 
eyes,  and  by  the  vitiated  air  of  lying-in  hospitals;  but  by  far  the 
most  frequent  cause  of  the  disease  is  the  matter  of  leucorrhcea 
or  of  gonorrhoea,  which  probably  is  applied  to  the  eye  while  the 
head  is  in  the  vagina.  If  the  mother  has  either  of  these  affections, 
or  indeed  any  morbid  secretion  from  her  vagina,  the  child,  unless 
its  eyes  be  carefully  washed  immediately  after  birth,  will  in  a 
large  majority  of  cases,  be  afflicted  with  the  disease. 

1074.  Ophthalmia  is  also  produced  in  adults,  by  the  gonorrhceal 
matter  being,  through  carelessness,  applied  to  the  eye.     Some- 
times, upon  the  suppression  of  a  discharge  from  the  urethra,  in- 
flammation of  the  conjunctiva  makes  its  appearance,  caused  as  it 
has  been  supposed  by  a  metastasis;  but  we  suspect  that  such  an 
occurrence  is  by  no  means  so  common  as  is  believed. 

1075.  The  purulent  secretion  from  the  inflamed  conjunctiva, 
like  all  other  morbid  secretions,  when  applied  to  the  eye,  will 
excite  inflammation.     Many  surgeons  have  disbelieved  this,  and 
M.  Hupsch,  a  surgeon  attached  to  the  army  of  the  Netherlands, 
was  so  incredulous,  that  he  submitted  to  be  inoculated  with  this 
secretion,  and  in  twenty-four  hours  he  was  attacked  with  an  in- 
flammation so  violent  as  to  endanger  his  sight.     M.  Kirkhoff 
inoculated  different  individuals  with  matter  flowing  from  patients 


DISEASES    OP    THE    EYES.  325 

afflicted  with  ophthalmia,  and  although,  in  so  doing,  he  scarcely 
touched  the  edges  of  the  eyelids,  and  in  such  a  manner  that  it 
could  not  act  as  a  foreign  body,  ophthalmia  followed  in  one,  two, 
or  three  days.  .  M.  Guille  also  introduced,  under  the  eyelids  of 
four  boys,  born  blind,  some  mucus  taken  from  the  eye  of  a  per- 
son labouring  under  purulent  ophthalmia,  and  they  were  removed 
from  all  other  infection  supposed  to  have  a  prejudicial  influence, 
and  inhabited  an  airy,  healthy  situation,  yet  they  each  had  an 
attack  of  purulent  ophthalmia.  We  have  seen  the  disease  in 
some  instances  communicated  to  several  in  a  family,  from  wiping 
on  the  same  towel  with  one  who  was  suffering  from  the  com- 
plaint. 

1076.  By  many  surgeons,  inflammation  of  the  conjunctiva,  at- 
tended with  puriform  discharge,  is  supposed  to  be  propagated  by 
a  specific  contagion.  So  eminently  contagious  does  Mr.  Ed- 
monston  consider  the  disease,  that  he  believes,  "  the  simple  in- 
spection of  the  eye  of  a  person  labouring  under  the  disease,  to 
be  sufficient  to  produce  it  in  another;"  and  in  proof  of  the  cor- 
rectness of  this  belief  he  relates  the  following  circumstance  with 
becoming  gravity: — "Two  Serjeants  came  one  day  to  the  hospi- 
tal together,  complaining  of  sore  eyes;  one  of  them  had  been 
affected  three  hours  before  he  made  any  application;  and  one 
hour  before  presenting  himself  at  the  hospital,  he  requested  his 
friend  to  look  at  his  eye.  The  other  complied,  and  declared  to  me 
that  while  looking  at  the  eye  of  his  comrade  he  felt  a  pain  in 
his  own.  Although  only  one  hour  had  elapsed  from  the  time  of 
the  first  uneasy  sensation,  the  tunica  adnata  was  covered  with 
blood,  and  the  watery  effusion  had  taken  place."  The  question 
of  the  contagious  nature  of  this  disease  has  been  amply  examined 
by  us  in  the  thirteenth  volume  of  the  Philadelphia  Journal  of  the 
Medical  and  Physical  Sciences;  and  we  think  it  has  there  been 
shown  that  there  is  not  a  particle  of  evidence  of  this  disease  being 
propagated  by  a  specific  virus. 

1077.  Inflammation  of  the  conjunctiva  sometimes  prevails  epi- 
demically. At  the  commencement  of  the  present  century  it  is 
said  to  have  spread  over  France,  Holland,  and  almost  the  whole 
of  the  north  of  Europe.  During  the  months  of  February  and 
March,  1803,  this  disease  prevailed  very  generally  over  Paris. 
It  commenced  about  the  26th  of  February,. and  before  the  20th 
of  March  nine-tenths  of  the  inhabitants  of  every  class  had  been 
affected  with  it.  The  complaint  was  so  common,  that  it  was  de- 
nominated maladie  d  la  mode.  Strangers  arriving  in  Paris  in 
perfect  health,  were  often  attacked  the  day  after  their  arrival. 
The  disease  was  often  connected  and  alternated  with  the  influ- 
enza, which  had  raged  in  that  city  for  a  considerable  time,  and 


326  DISEASES    OF    THE    EYES. 

was  then  beginning  to  abate.  *  It  occurred  frequently  with  the 
influenza  that  prevailed  in  Philadelphia  during  the  winter  of 
1826—7. 

1078.  Such,  as  I  have  enumerated  them,  are  the  usual  causes 
of  inflammation  of  the  conjunctiva;  and  according  to  the  acti- 
vity of  these  causes  will  be  the  violence  and  extent  of  the  in- 
flammation, while  its  character  will  be  modified  in  some  degree 
by  the  peculiarities  of  the  constitution,  of  the  individual  in  which 
it  occurs. 

1079.  Inflammation  of  the  conjunctiva  may  be  divided  into 
acute  and  chronic,  though  the  latter  is  often  only  an  imperfectly 
cured  state  of  the  former;  it  nevertheless  sometimes  exists  with- 
out any  well-marked  preceding  acute  stage. 

Symptoms  of  Acute  Inflammation. 

1080.  Acute  inflammation  usually  commences  in  the  palpebral 
conjunctiva,  the  vessels  of  which  first  become  engorged,  and  may 
be  often  seen  running  in  fasciculi,  and  sometimes  slightly  elevat- 
ed; the  natural  secretion  of  the  part  seems  suppressed,  and  its  sen- 
sibility exalted.  The  engorgement  of  the  vessels,  with  suppression 
of  their  secretions,  produces  a  sensation  of  fulness  and  dryness, 
sometimes  an  itching,  with  a  disposition  to  rub  the  eye;  as  the 
eyelid  passes  over  the  ball,  the  elevated  vessels  rubbing  upon 
the  sclerotic  conjunctiva,  a  sensation  as  if  a  grain  of  sand  or  some 
foreign  body  were  in  the  eye  is  produced,  and  it  is  frequently 
almost  impossible  to  convince  the  patient  that  this  sensation  is 
deceptive.     From  the  accumulation  of  blood  in  the  conjunctival 
vessels  there  is  increased  redness,  and  the  blood  also  being  the 
great  source  of  animal  heat,  the  temperature  of  the  eye  is  aug- 
mented, and  as  the  sensibility  of  the  part  is  exalted,  a  sensation 
of  burning  is  often  experienced.   This  constitutes  the  first  stage, 
or  that  of  simple  engorgement. 

1081.  In  the  second  stage  the  vessels  relieve  themselves  by  an 
increased  secretion ;  the  meibomian  glands  are  usually  impli- 
cated, and  their  secretion  which  in  the  first  stage  is  often  sup- 
pressed, now  becomes  increased,  after  a  while  vitiated  in  quality, 
and  during  the  night  its  more  fluid  parts  being  absorbed,  the 
lids  are  glued  together  and  are  with  difficulty  opened  in  the 
morning.  The  excretory  ducts  of  these  glands  are  often  blocked 
up  by  an  incrustation  of  this  secretion,  and  if  care  be  not  taken 
to  remove  it,  ulceration  will  be  produced.  The  lachrymal  gland, 
soon   sympathizes   in  the   disease,  its  secretion  is  sometimes 
lessened,  at  others  suppressed,  most  frequently  it  is  increased 

*  Edmonston,  Treatise  on  Ophthalmia,  p.  49. 


DISEASES    OF    THE    EYES.  327 

in  quantity,  and  from  the  exalted  sensibility  of  the  parts,  pro- 
duces a  sensation  of  scalding ;  after  a  time  it  becomes  vitiated  in 
quality  and  produces  an  excoriation  of  the  cheek  over  which'  it 
passes.  The  redness,  which  at  first  was  confined  to  the  palpe- 
bral  conjunctiva,  now  spreads  over  the  sclerotic  portion. 

1082.  In  the  third  stage  th&  redness  becomes  more  uniform 
and  intense,  and  the  conjunctiva  assumes  a  villous  appearance. 
Effusion  takes  place  in  and  beneath  the  cdnjunctiva,  usually  com- 
mencing in  the  palpebral  portion.     This  effusion  consists  of  a 
serous  fluid,  sometimes  when  the  inflammation  is  violent,   of 
blood.     In  proportion  to  the  quantity  of  this  effusion,  the  con- 
junctiva becomes  thickened,  and  as  the  palpebral  portion  swells, 
it  everts  the  lids,  producing  what  is  called  entropion.     The 
sclerotic  portion  also  becomes  thickened,  elevated,,  often  pro- 
trudes between  the  lids ;  while  the  cornea  appears  deeply  sunk 
in  the  globe,  the  conjunctiva  covering  the  cornea,  being  so  in- 
timately connected  with  that  part,  as  not  to  admit  of  effusion 
beneath  it.     This  condition  of  the  sclerotic  conjunctiva  is  called 
chemosis.      The.  secretion   from  the  free  surface  of  the  con- 
junctiva is  increased,  and  assumes  a  puriform  character;  the 
quantity  of  purulent  fluid  secreted  from  this  part  is  often  sur- 
prisingly great,  greater  perhaps  than  from  any  other  mucous 
membrane  of  equal  extent ;  we  have  frequently  seen  pus  run 
from  the  eye  in  a  continuous  stream.  The  retina  now  often  sym- 
pathizes with  the  conjunctiva,  and  there  is  intolerance  of  light ; 
which  is  frequently  so  great,  especially  in  children,  that  it  is  ex- 
tremely difficult  and  sometimes  impossible,  to  open  the  lids  so 
as  to  examine  the  globe  of  the  eye.     Even  when  we  succeed  in 
separating  the  lids,  the  orbicularis,  in  consequence  of  the  pho- 
tophobia and  irritation  of  the  disease,  contract  with  such  power, 
as  to  produce  an  eversion  of  the  lids  and  the  protrusion  of  the 
swelled  conjunctiva  still  impedes  the  view.     When  the  lids  are 
everted  in  the  effort  to  examine  the  eye,  great  care  should  always 
be  taken  to  restore  it  to  its  proper  condition,  or  serious  conse- 
quences may  result.    Their  restoration  may  be  accomplished  by 
pulling  gently  at  the  eyelash,  and  if  it  does  not  succeed,  by 
pressing  at  the  same  time  upon  the  protruded  conjunctiva. 

1083.  Coagulable  lymph  is  next  effused  into  the  conjunctiva, 
which  becoming  organized  that  membrane  assumes  a  fleshy  ap- 
pearance.    At  this  period  or  even  earlier,  the  cornea,  sclerotica 
and  the  internal  parts  of  the  eye  become  implicated,  and  there  is 
then  in  addition  to  the  symptoms  of  inflammation  of  the  conjunc- 
tiva, all  the  effects  of  inflammation  of  the  whole  globe. 

1084.  As  long  as  the  inflammation  is  confined  to  the  conjunc- 
tiva, the  pain  is  trifling;  we  have  seen  the  conjunctiva  of  an  uni- 
form red  colour,  elevated  all  round  the  cornea,  the  eyelids  swell- 


328  DISEASES    OF    THE    EYES. 

ed,  and  the  discharge  of  pus  profuse,  and  yet  the  patient  not 
complain  of  pain.  But  when  the  other  membranes  of  the  eye 
become  affected,  the  pain  is  excruciating;  there  is  an  increased 
secretion  of  aqueous  humour,  the  eyeball  feels  distended,  with 
an  occasional  sensation  as  if  needles  were  thrust  into  the  eye,  ac- 
companied with  fulness  and  throbbing  of  the  temples  and  deep- 
seated  pain  in  the  globe  of  the  eye.  This  pain  is  often  inter- 
mittent; at  one  moment  it  will  be  very  violent,  at  the  next  it 
will  disappear,  and  sometimes  it  shifts  instantly  from  one  eye  to 
the  other. 

1085.  At  this  period  the  cornea  sometimes  ulcerates,  and  its  in- 
ternal lamina  is  projected  forward  by  the  pressure  of  the  aqueous 
humour ;  at  other  times  the  cornea  ruptures,  the  iris  is  forced 
through  the  opening,  and  occasionally  closes  it — notunfrequently 
rapid  sloughing  of  the  cornea  takes  place,  the  whole  contents 
of  the  .globe    are  discharged,  and   sight  irrevocably  lost.     It 
occasionally  happens  that  the  cornea  sloughs  extensively,  the 
aqueous  humour  is  evacuated,  and  the  lens  covered  only  by  its 
capsule,  advances  against  the  opening;  under  these  circumstances, 
the  patient  who  has  long  been  deprived  of  vision,  sees  very  dis- 
tinctly, and  enjoys  the  most  pleasing  anticipations  of  an  entire 
recovery  of  sight,  but  the  capsule  soon  bursts,  and  the  disap- 
pointed victim  is  plunged  into  utter  and  perpetual  darkness. 

1086.  The  violence  of  the  disease  being  thus  expended,  the 
redness  generally  subsides ;  absorption  of  the  effused  lymph  and 
serum  commences,  lessening  the  tumefaction  of  the  lids,  and 
with  it  the  inversion  of  the  tarsi.     But  if  the  inflammation  has 
continued  for  any  length   of  time,  the  conjunctiva  has  become 
thickened,  indurated,  and  near  the  edges  of  the  tarsi  especially, 
granulated;  and  when  the  oedema  of  the  lids  disappears,  the  edges 
of  the  eyelids  are  more  or  less  inverted,  according  to  the  greater 
or  less  degree  of  the  diseased  or  granulated  state  of  the  palpebral 
conjunctiva.     If  the  inversion  is  considerable,  the  sclerotic  con- 
junctiva, from  exposure,  or  in  other  instances  from  the  irritation 
produced  by  a  granulated  palpebral  conjunctiva,  is  kept  in  a  con- 
stant state  of  irritability  or  chronic  inflammation,  and  by  the 
slightest  causes,  acute  disease  is  frequently  and  readily  excited. 
If  relief  is  not  now  speedily  afforded,  the  cornea  becomes  per- 
manently disorganized,  thickened,  often  ulcerated,  and  staphy- 
loma  or  prolapsus  iridis  results,  or  the  contents  of  the  globe  are 
lost. 

1087.  Such  is  the  course  of  inflammation  of  the  conjunctiva,  but 
the  progress  of  the  disease  cannot  always  be  distinctly  traced, 
nor  does  it  always  run  the  regular  course  we  have  described. 
Sometimes  it  proceeds  with  such  rapidity  as  to  arrive  at  its  ut- 
most violence  in  a  few  hours,  at  others  its  progress  is  very  slow. 


DISEASES    OF    THE    EYES.  329 

In  many  instances  the  disease  continues  in  its  first  stage  for  days, 
weeks,  and  even  months,  or  only  advances  to  the  second  stage, 
and  then  subsides  entirely ;  in  others,  some  exciting  cause  rouses 
the  disease  into  activity,  and  then  it  may  run  its  course  with 
extreme  rapidity. 

Symptoms  of  Chronic  Inflammation. 

1088.  The  progress  of  chronic  inflammation  of  the  conjunctiva 
is  very  irregular.     It  usually  commences,  like  the  acute,  in  the 
palpebral  conjunctiva,  and  is  often  confined  principally  to  that 
part.   The  conjunctiva  becomes  of  a  uniform  redness,  and  a  little 
livid,  it  is  thickened  by  an  effusion  of  lymph,  and  converted  into 
a  dense  reddish  tissue  of  a  fleshy  appearance.  There  is  lachryma- 
tion,  with  a  slight  puriform  discharge,  and  an  increase  of  the  se- 
cretion from  the  meibomian  glands,  by  which  the  eyelids  are 
glued  together  at  night. 

1089.  Little  pustules  sometimes  form,  which  burst  and  dis- 
charge an  ichorous  fluid,  leaving  small  ulcers;  these  extend  over 
the  whole  edge  of  the  tarsus,  especially  the  lower,  and  if  not 
cured,  involve  and  destroy  the  ciliary  follicles;  the  ciliae  of  course 
fall  out,  and  the  fine  cuticle  of  the  lid  becomes  excoriated.  This 
form  of  the  disease  is  very  common  in  children,  and  sometimes 
lasts  the  principal  part  of  their  lives.  When  this  happens,  it  is,  we 
believe,  the  fault  either  of  the  patient  or  the  practitioner,  as  we 
have  never  seen  a  case  with  the  requisite  attention,  resist  proper 
treatment  for  one  month;  and  we  have  cured  cases  of  eighteen 
and  twenty  years  duration  in  less  time. 

1090.  We  have  mentioned  among  the  sequelse  of  acute  inflam- 
mation, a  granular  state  of  the  palpebral  conjunctiva.    This  state 
is  also  frequently  produced  by  chronic  inflammation  of  a  very 
slight  character.   Granulations  are  small  round  bodies,  sometimes 
of  a  fleshy  appearance  and  consistence;  at  others  pale,  and  of  a 
hard  cartilaginous  nature ;  and  not  unfrequently  of  a  soft  texture 
and  dark  colour,  like  clots  of  coagulated  blood,  and  discharge 
that  fluid  copiously  upon  being  slightly  touched,  even  in  some 
cases  by  the  mere  motion  of  the  lids.     They  are  generally  dis- 
persed over  the  whole  of  the  inner  surface  of  the  lids,  sometimes 
they  appear  confined  to  particular  parts,  and  are  always  most 
luxuriant  at  the  edges  of  the  tarsi.  The  irritation  caused  by  these 
granulations,  keep  up  a  constant  chronic  inflammation  of  the  scle- 
rotic conjunctiva  and   cornea;  and  where  the  inflammation  of 
these  parts  appear  to  be  the  only  affection,  on  examination  it  will 
often  be  found  to  be  entirely  dependent  upon  the  s"tate  of  the 
palpebral  conjunctiva  we  have  described, 

42 


330  DISEASES   OF    THE    EYES. 

1091.  We  pass  over  the  other  effects  of  chronic  inflammation 
as  of  minor  importance,  or  as  appertaining  more  particularly  to 
the  province  of  surgery. 

Inflammation  of  the  Conjunctiva  in  Irritable  Constitutions. 

1092  This  form  usually  occurs  in  children  of  irritable  habits, 
with  swelled  abdomens,  disposition  to  enlarged  lymphatic  glands, 
and  that  state  of  constitution  usually  designated  by  the  vague 
term  scrofulous.  It  is  remarkable  for  the  great  intolerance  of 
light  which  attends  it,  and  which  is  entirely  disproportionate  to 
the  amount  of  inflammatory  action.  In  these  cases,  from  pecu- 
liarity of  constitution,  the  retina  promptly  sympathizes  with  the 
conjunctival  inflammation,  and  hence  the  photophobia. 

1093.  In  the  description  of  persons  we  are  now  speaking  of, 
the  disease,  as  in  the  other  forms,  commences  in  the  palpebral 
conjunctiva;  there  is  often  some  pain  at  first,  which  generally  after- 
wards disappears;  and  profuse  lachrymation,  the  tears  being  hot 
and  acrid,  and  irritating  the  cheek  over  which  they  pass.   From 
the  great  intolerance  of  light,  the  child  usually  has  its  hands  to 
its  eye?,  and  its  head  is  constantly  buried  in  its  nurse's  lap,  or  in 
its  pillow.   Extreme  difficulty  is  always  experienced  in  examin- 
ing the  little  patient's  eyes,  even  the  ordinary  light  of  day  being 
intolerable. 

1094.  The  meibomian  glands  are  always  implicated,  their  se- 
cretion is  vitiated,  and  ulceration  of  the  tarsi  often  occurs,  also 
chronic  thickening  of  the  palpebral  conjunctiva;  the  cornea  be- 
comes generally  affected,  as  is  shown  by  the  effusion  of  lymph, 
producing  opaque  spots.     This  opacity  is  rarely  general. 

1095.  The  form  of  inflammation  we  are  now  considering,  also 
frequently  appears  with  cuticular  disease,  and  alternates,  or  is 
concomitant  with  sore  eyes,  sore  head,  or  eruptions  on  the  head 
and  face,  and  similar  marks  of  deranged  constitution. 

Pustular  Conjunctival  Inflammation. 

1096.  The  conjunctiva,  like  other  mucous  membranes,  is  lia- 
ble to  the  formation  of  pustules,  they  usually  occur  on  the  cor- 
nea or  near  its  margin.     We  shall  describe  them  in  treating  of 
inflammation  of  the  cornea. 

Treatment. 

1097.  The  treatment  of  inflammation  of  the  conjunctiva  con- 
sists in  the  reduction  of  the  inflammatory  action,  and  this  may 


DISEASES    OF    THE    EYES.  331 

be  effected  by  the  use  of  general  and  local  remedies,  either  alone 
or  conjoined,  as  may  be  required.  Among  the  former  may  be 
mentioned  general  blood-letting,  emetics,  nauseating  doses  of 
antimonials,  purgatives,  diaphoretics,  &c.;  the  latter  consists  of 
local  bleeding,  blisters,  and  various  astringent  and  stimulating 
applications. 

1.  Blood-letting. 

1098.  This  is  unquestionably  one  of  the  most  important  means 
for  subsiding  inflammation;  but  to  be  of  utility  it  must  be  pro- 
perly employed,  and  we  shall  therefore  enter  into  a  full  consi- 
deration of  this  remedy. 

1099.  In  the  forming  stage,  when  this  stage  is  distinctly  mark- 
ed, the  inflammation  is  usually  mild,  and  venesection  is  rarely 
demanded. 

1100.  In  the  second  stage,  a  moderate  bleeding  from  the  arm 
will  frequently  be  required  ;  and  it  will  be  often  necessary,  after- 
wards, to  detract  blood  locally  by  cups  or  leeches  to  the  temples 
or  behind  the  ears.  In  some  cases,  topical  depletion  will  be  suf- 
ficient.    The  quantity  of  blood  to  be  detracted  in  all  cases  must 
be  determined  by  the  urgency  and  violence  of  the  inflammation, 
and  the  constitution  of  the  patient.    No  precise  rules  can  be  laid 
down  on  this  subject;  and  it  is  here  that  the  physician  will  find 
it  necessary  to  employ  all  his  discernment  and  experience.  When, 
however,  the  symptoms  of  this  stage  are  violent,  and  the  disease 
threatens  to  run  speedily  into  the  next  stage,  depletion  must  be 
carried  to  the  same  extent  as  will  be  devised  for  the  treatment 
of  the  third  stage. 

1101.  In  the  third  stage  the  safety  of  the  eye  depends  upon 
the  boldness  with  which  blood  is  drawn.     When  the  inflamma- 
tion is  very  violent,  it  runs  through  the  first  and  second  stages, 
with  such  rapidity,  that  when  the  patient  is  first  seen,  there  is 
usually,  already  chemosis,  purulent  discharge,  lachrymation,  &c. 
No  time  is  here  to  be  lost;  moderate  depletion  is  worse  than 
useless,  weakening  the  patient  without  lessening  the  inflamma- 
tory action.    A  vein  should  be  opened  in  the  arm  and  the  blood 
allowed  to  flow  till  a  decided  impression  is  made  upon  the  sys- 
tem.    The  first  to  recommend  blood-letting  to  such  an  extent, 
was  Mr.  Peach.  He  advises  blood  to  be  detracted  ad  deliquium 
animi,  without  regard  to  the  quantity;  he  once  at  a  single  bleed- 
ing took  77?  ounces,  which  completely  overcame  the  disease, 
nor  had  it  any  pernicious,  or  even  the  slightest  ill  effect  on  the 
general  health  of  the  patient.     We  suspect  however,  that  it  will 
rarely  be  necessary  to  draw  blood  to  such  an  extent,  fainting  be- 
ing usually  produced  if  the  patient  be  bled  in  an  upright  position 


332  DISEASES    OP    THE    EYES. 

before  twenty  ounces  are  detracted.   In  cases,  says  Mr.  Vetch,* 
"  where  the  patient  is  capable  of  losing  a  very  large  quantity  of 
blood,  as  soon  as  the  countenance  is  observed  to  change,  in  the 
full  assurance  that  a  state  of  deliquium  will  succeed,  the  arm 
may  be  bound  up.    I  found  experience  of  great  use  in  informing 
me  whether  this  event  would  take  place  or  not,  saving  by  this 
means  the  necessity  of  suffering  the  blood  to  flow  until  syncope 
actually  came  on;  but  the  unexperienced  must  be  cautious,  and 
not  trust  to  this  issue,  for  if  it  does  not  succeed,  and  the  orifice 
be  again  to  be  opened,  the  system  having  had  time  to  rally,  more 
blood  will  be  abstracted  than  if  no  interruption  had  taken  place. 
The  erect  posture  is  well  known  to  be  favourable  to  the  success 
of  the  operation,  in  inducing  syncope.     Opening  a  vein  in  both 
arms  is  also  recommended,  but  so  harsh  a  practice  need  seldom 
be  employed.     The  fear  of  the  operation,  it  is  well  known,  will 
often  occasion  both  nausea  and  syncope,  but  I  never  found  that 
the  latter  produced  in  this  way  was  to  be  relied  upon  as  a  sub- 
stitute for  the  further  evacuation  of  blood.  It  was  observed,  that 
at  a  second  blood-letting,  though  repeated  in  a  short  time  after 
the  first,  the  quantity  necessary  to  produce  syncope  was  gene- 
rally larger  than  was  lost  by  the  first  operation.  Before  the  prin- 
ciple on  which  the  success  of  this  remedy  chiefly  depends  was 
properly  understood,  when  large  blood-lettings  were  more  fre- 
quently repeated,  and  when,  on  the  whole,  much  more  blood  was 
abstracted  than  by  the  practice  I  recommend,  the  sensible  change 
produced  on  the  appearance  of  the  blood  itself,  was  a  diminution 
of  the  relative  quantity  of  crassamentum  to  the  serum,  and  of  the 
specific  gravity  of  the  mass.     The  serum  seemed  also  to  hold  a 
greater  quantity  either  of  gelatine,  or  albumen  in  solution,  as  it 
sometimes  became  white  and  turbid.     The  average  quantity  of 
blood  abstracted  before  the  approach  of  syncope  appeared  to  be 
from  twenty-four  to  thirty -four  ounces." 

1102.  With  the  exception  of  symptoms  of  ephemeral  fever, 
and  the  temporary  debility  which  must  of  course  follow  the  loss 
of  blood  and  a  spare  diet,  Mr.  Vetch  says,  that  he  never  could 
trace  any  constitutional  disease,  weakness,  or  derangement  to  be 
connected  with  this  treatment.  He  adds  however,  "there  are 
two  descriptions  of  habit  and  temperament  in  which  the  system 
is  longer  in  recovering  from  large  blood-letting  than  in  others," 
"the  first  is  that  of  corpulency,  and  the  other  where  the  powers 
of  the  mind  have  been  more  developed  than  those  of  the  body, 
and  attended  with  irritability  of  both.  Men  of  a  spare  thin  mus- 
cular frame  universally  lost  a  greater  quantity  of  blood,  without 

•  Opera  Citata,  p.  221,  &c. 


DISEASES   OP   THE    EYES.  333 

exhibiting  any  alteration  of  countenance  or  disposition  to  syn- 
cope. 

1103.  "Fat  people,  or  those  who  have  a  tendency  to  the  for" 
mation  of  fat,  faint  by  the  loss  of  a  small  quantity  of  blood.   Al- 
though such  people  may  be  liable  to  disease,  arising  from  the 
obstructed  passage  of  the  blood  in  particular  parts  of  organs,  I 
believe  there  are  none  in  whom  the  existence  of  real  plethora  is 
more  rare.     The  deposition  of  fat  withdraws  something  from 
the  quantity  of  blood  made  by  the  system,  while,  by  enlarging 
the  surface  of  the  body,  a  greater  quantity  of  that  fluid  is  required 
to  maintain  the  vigorous  action  of  the  extreme  vessels." 

1104.  In  drunkards  and  those  of  broken  or  extremely  delicate 
constitutions,  in  whom  the  power  of  reaction  is  very  feeble,  blood 
must  be  drawn  more  cautiously:  the  chance  of  a  cure  in  such 
persons  is  of  course  less.   The  practitioner  must  not  however  be 
deterred  from  active  depletion,  because  the  pulse  does  not  indi- 
cate blood-letting.     No  greater  error  can  be  committed  in  prac- 
tice, than  that  of  omitting  to  detract  blood  in  cases  where  we 
have  evidence  of  local  inflammation,  because  the  pulse  does  not 
indicate  it.  Inflammation  may  go  on  to  the  destruction  of  a  part, 
without  the  heart  sympathizing  or  being  at  all  excited.     The 
absence  of  pain  must  not  mislead  either.   This  symptom  is  often 
absent  in  inflammation,  especially  of  mucous  membranes,  and 
if  a  favourable  termination  is  anticipated  from  the  absence  of 
this  symptom,  and  mild  measures  adopted,  the  most  melancholy 
consequences  will  result.     We  have  lately  seen  a  case  of  puru- 
lent inflammation  of  the  conjunctiva  commencing  in  one  eye,  in 
which  the  physician  was  deterred  from  general  depletion  by  the 
state  of  the  patient's  pulse.     Topical  depletion  by  cups  was  se- 
veral times  resorted  to,  but  without  arresting  the  disease,  and  as 
the  patient  bore  the  local  depletion  well,  and  as  the  other  eye 
was  becoming  affected,  venesection  was  cautiously  resorted  to, 
and  afterwards  vigorously  pursued.     The  time  lost  in  the  first 
instance,  was  however,  fatal  to  the  eye  first  attacked;  the  other 
eye  was  saved  by  the  copious  blood-letting  afterwards  employed. 

1105.  If  the  acute  symptoms  return  after  the  first  bleeding,  the 
operation  must  be  repeated  to  a  greater  or  less  extent  according 
to  the  violence  of  the  disease. 

1106.  Opening  the  temporal  artery  or  jugular  vein,  has  been 
recommended  as  more  effectual  than  venesection,  but  we  con- 
sider it  to  be  obnoxious  to  many  objections. 

1107.  After  general  depletion  has  been  carried  as  far  as  pru- 
dence will  justify,  if  the  disease  be  not  subdued,  we  must  have 
recourse  to  topical.     This  may  be  effected  by  cups  or  leeches, 
and  the  best  place  to  apply  them  is  to  the  temples  or  to  the  back 
of  the  neck.     Some  practitioners  apply  leeches  to  the  lids,  to 


334  DISEASES    OF    THE    EYES. 

the  eyeball,  and  to  the  palpebral  conjunctiva,  first  inverting  the 
lid:  we  have  never  seen  them  applied  to  these  situations  in 
acute  inflammation,  without  their  being  productive  of  injury. 

1108.  Scarifications  of  the  conjunctiva  have  been  extolled  as 
extremely  useful.   When  there  is  chemosis  and  after  the  violence 
of  the  inflammation  has  been  subdued  by  other  measures,  scarifi- 
cations may  be  useful;  they  should  be  made  freely  and  bleeding 
encouraged  by  warm  fomentations.   In  acute  inflammation,  where 
there  is  no  chemosis,  we  have  found  them  invariably  detrimen- 
tal ;  adding  greatly  to  the  irritation.     There  is  another  mode  of 
topical  depletion,  which  has  been  long  practised,  and  particularly 
recommended  by  the  late  Mr.  Ware.    This  consists  in  the  exci- 
sion of  a  portion  of  the  conjunctiva  including  the  turgid  vessels 
on  its  surface.   Mr.  Ware  considers  this  as  preferable  to  a  simple 
division  of  the  vessels,  as  in  the  latter  case,  reunion  of  the  ves- 
sels often  takes  place  almost  immediately.*  In  the  first  or  second 
stages  of  the  disease,  I  should  consider  this  altogether  inadmis- 
sible, from  the  pain  and  irritation  it  would  excite ;  but  when 
there  is  chemosis,  or  when  the  inflammation  has  subsided  and 
left  the  vessels  in  a  varicose  state,  it  will  no  doubt  be  often  use- 
ful.    The  operation  may  be  performed  by  raising  the  part  or 
vessels  to  be  excised  by  a  small  hook  and  dividing  them  with 
scissors. 

2.  Purgatives, 

1109.  As  co-operating  with  the  depletory  measures  already 
recommended  and  as  producing  a  determination  from  the  head, 
purgatives  should  not  be  neglected.   Of  these  perhaps  the  Epsom 
salt  is  the  best,  it  may  be  given  alone  or  combined  with  emetic 
tartar,  as  follows;  sal.  Epsom,  ^j.  and  tart.  emet.  gr.  j.  in  solu- 
tion. This  will  be  found  a  very  useful  combination,  it  evacuates 
the  bowels,  produces  a  determination  from  the  head,  and  by  the 
slight  nausea  it  induces,  lessens  arterial  action;  it  may  be  repeat- 
ed every  day,  or  every  other  day,  according  to  circumstances. 

3.  Nauseating  Doses  of  Jlntimonials. 

1110.  After  the  system  has  been  reduced  by  general  depletion, 
tartar  emetic  given  in  small  doses,  so  as  to  produce  nausea,  will 
be  found  eminently  serviceable.     Nauseapts  will  not  answer  as 
substitutes  for  more  vigorous  measures,  but  they  are  highly  use- 
ful as  adjuvants,  in  keeping  down  arterial  action.     They  may  be 
used  with  advantage  where  there  is  a  great  tendency  to  inflam- 

*  Chirurgical  Observations,  &c.  p.  40,  41. 


DISEASES   OP    THE    EYES.  335 

mation,  and  where  the  symptoms  show  a  disposition  to  become 
aggravated  as  soon  as  the  system  recovers  from  the  state  pro- 
duced by  previous  evacuants. 

1111.  We  commonly  combine  the  emetic  tartar  with  nitre, 
and  sometimes,  calomel,  in  the  form  of  the  nitrous  powders,  and 
we  think  with  great  ad  vantage.  Sal.  nitre,  5jss'*>  tart-  emet.  gr.j.; 
calomel,  gr.  vj.;  div.  in  chart,  vj.;  one  to  be  given  every  one, 
two,  or  three  hours. 

4.  Diaphoretics. 

1112.  In-  violent  conjunctivitis,  diaphoretics  are  rarely  indicat- 
ed, but  in  the  early  stages  of  mild  inflammation,  and  when  the 
affection  is  combined  with  catarrhal  symptoms,  they  may  be  used 
with  advantage.  The  best  is  probably  the  Dover's  powder;  of  this 
ten  grains  may  be  given  at  night,  and  perspiration  promoted  by 
draughts  of  hot  lemonade.  Dr.  Kirkhoff  says,  that  he  has  several 
times  found,  that  tf  the  warm  bath  was  frequently  used  the  mo- 
ment the  earliest  symptoms  appeared,  the  disease  might  be  at 
once  arrested;  but  if  inflammation  was  already  established,  this 
application  served  only  to  increase  it.     Hot  pediluvia,  to  which 
mustard  should  be  added,  are  often  productive  of  great  utility. 

5.   Tonics. 

1113.  In  patients  of  weak  and  irritable  habits,  or  those  whose 
constitution  is  destroyed  by  the  excessive  use  of  ardent  spirits, 
&c.  the  inflammation  early  spreads  to   the  cornea,  producing 
ulceration  and  sloughing  of  this  part.     The  edges  of  the  wound 
appear  ragged  and  unhealthy,  and  the  strength  of  the  patient  is 
mostly  prostrate.     In  such  cases  tonics  will  be  demanded;  the 
best  are  the  cinchona,  sulphate  of  quinine,  and  sulphuric  acid. 

6.  Diet. 

1114.  During  the  existence  of  acute  inflammation,  the  diet 
should  be  of  the  strictest  antiphlogistic  nature.    In  some  cases  it 
will  be  necessary  not  only  to  restrict  the  patient  to  bread  and 
water,  but  even  to  limit  the  quantity  of  the  former.  Toast-water 
alone  is  sometimes  sufficient.  Barley-water  or  rice-water  acidu- 
lated with  lemon-juice,  or  lemonade  may  at  other  times  be  allow- 
ed.    As  the  inflammation  abates,  rice,  sago,  oatmeal  gruel,  and 
panada,  may  be  taken;  also  the  acid  fruits,  grapes,  peaches,  &c. 
and  the  scale  of  diet  gradually  increased  as  the  inflammation 
ceases.     In  those  cases  in  which  we  have  recommended  tonics, 
(see  par.  1113,)  a  generous  diet  must  be  allowed;  this  may  con- 


336  DISEASES    OF    THE    EYES. 

sist  of  sago,  or  tapioca,  with  a  little  wine  or  spices,  light  and  di- 
gestible meats,  &c. 

7.  Blisters. 

1115.  As  in  other  inflammations,  blisters  have  been  highly 
recommended  in  that  of  the  conjunctiva.     However  useful  they 
may  be  in  other  inflammations,  and  though  in  some  varieties  of 
ophthalmia   the   advantages    derived    from   them    are  decided, 
yet  in  the  affection  under  consideration  their  utility  is  by  no 
means  unequivocal.     When  applied  near  the  seat  of  the  dis- 
ease, particularly  in  the  early  stages,  we  have  never  seen  them 
fail  to  aggravate  the  inflammation.     The  excitement  which  they 
produce  extends  to  the  eyes,  and  their  application  is  found  to  be 
injurious  rather  than  beneficial.     But  in  the  latter  stages  of  the 
disease,  where  there  is  a  good  deal  of  local  action,  and  after  de- 
pletory measures  had  been  used,  blisters  applied  behind  the  ears 
or  to  the  nape  of  the  neck  may  be  found  serviceable.  Some  prac- 
titioners recommend  the  blisters  to  be  put  over  the  eye,  and  as- 
sure us  that  they  are,  when  thus  applied,  productive  of  much 
benefit;  we  have  only  to  regret  that  in  our  experience  such  has 
not  been  the  result. 

8.  Local  Applications  to  the  Eye. 

1116.  We  confess  ourselves  to  be  at  a  loss  how  to  convey  to 
our  readers  instructions  for  the  employment  of  this  class  of  re- 
medies.    When  judiciously  used,  they  save  the  patient  a  great 
amount  of  suffering,  and  the  physician  an  infinity  of  trouble; 
when  improperly  employed, they  not  only  aggravate  and  lengthen 
the  disease,  but  often  prove  even  destructive  of  vision.     We 
have  known  patients  in  whom  all  acute  inflammation  had  been 
subdued,  and  the  vessels  continuing  to  convey  red  blood  from 
mere  weakness  or  inability  to  contract  to  their  natural  dimensions, 
restricted  to  the  lowest  diet,  repeatedly  bled,  and  daily  purged; 
the  disease  all  the  time  remaining  stationary,  while  the  patient's 
strength  was  becoming  exhausted,  and  a  most  distressing  nervous 
state  produced.   In  this  condition,  losing  all  patience,  they  have 
sometimes  dismissed  their  medical  attendant,  and  applied  to  an- 
other practitioner,  who  has  cured  them  at  once  by  the  employ- 
ment of  a  stimulating  ointment.  It  much  more  frequently,  how- 
ever, happens,  that  irreparable  mischief  is  produced  from  the 
use  of  these  remedies  at  an  improper  stage  of  the  disease.  Those 
afflicted  with  ophthalmia  often  lose  their  patience  before  the 
inflammation  has  been  subdued,  or  neglect  to  take  proper  ad- 
vice, and  apply  to  their  eyes  at  the  recommendation  of  some 


DISEASES    OF    THE    EYES.  337 

kind  friend  or  busy  gossip,  a  stimulating  ointment  or  wash, 
whence  often  results  so  violent  an  aggravation  of  the  inflamma- 
tion as  to  prove  entirely  destructive  of  sight.  Dr.  Rowley, 
in  his  Treatise  on  the  Diseases  of  the  Eyes,  says,  "  I  can  speak 
from  an  experience  which  few  have  ever  enjoyed,  that  scarce 
one  instance  of  blindness  amongst  hundreds  has  happened,  in 
which  I  could  not  trace  the  misfortune  to  be  principally  owing 
to  poultices  or  some  ignorant  outward  application^  while 
the  eyes  were  inflamed.  The  phrase  of  *  the  eyes  are  not  to  be 
tempered  with,'  is  almost  proverbial;  yet,  ignorance  dares,  no 
doubt  with  the  best  and  most  humane  intentions,  to  prescribe 
injurious  remedies  in  the  most  difficult  and  dangerous  diseases. " 
A  favourite  remedy  with  many  "old  women"  of  this  city,  is 
molasses,  probably  in  consequence  of  their  having  seen  it  useful 
in  removing  opacities  of  the  cornea;  for  when  applied  to  the  eye 
after  all  inflammation  has  disappeared,  it  is  sometimes  successful 
in  stimulating  the  absorbents  to  the  removal  of  the  coagulable 
lymph  effused  during  inflammation.  Having  observed  it  useful 
under  such  circumstances,  with  that  want  of  discrimination  which 
always  characterizes  ignorance,  they  apply  it  indiscriminately  in 
all  the  stages  of  inflammation;  and  no  sooner  does  one  of  these 
officious  gossips  see  a  child  with  an  inflamed  eye,  than  she  forth- 
with thrusts  her  finger  into  the  molasses  bowl,  and  separating 
the  eyelids  of  her  unfortunate  victim,  she  wipes  her  finger  over 
the  eyeball;  as  may  be  supposed,  the  inflammation  is  always 
aggravated,  and  often  to  such  a  degree  as  speedily  and  irrecovera- 
bly to  destroy  the  sight.  We  are  afraid  to  mention  the  number 
of  victims,  we  have  seen,  to  this  practice. 

1117.  The  careful  and  observant  practitioner  soon  acquires  a 
tact  in  the  use  of  these  remedies,  which  it  is  impossible  to  con- 
vey by  language;  we  shall  lay  down,  however,  some  general 
directions,  which  will,  we  think,  prevent  any  great  error  in  the 
employment  of  local  applications. 

1118.  Local  applications  may  be  divided  into  those  which  act 
principally  by  their  temperature,  and  those  which  are  stimulating 
or  astringent.      Cold  effusions  have  been  employed  from  the 
earliest  periods.  Bartolinus  states  that  a  physician,  his  colleague, 
cured  himself  of  an  ophthalmia  by  the  application  of  a  snow-ball. 
M.  Beaupre  is  of  opinion,  that  when  the  disease  is  produced  by 
an  internal  cause  or  cold,  that  cold  applications  are  improper; 
but  when  it  is  excited  by  the  introduction  of  irritants  into  the 
eye,  cold  may  be  had  recourse  to  with  great  advantage.  The  ir- 
ritant being  first  removed,  these  applications  usually  relieve  the 
pain,  dissipate  the  redness,  and  prevent  the  progress  of  inflam- 
mation.    The  best  cold  applications  are  cold  water,  solutions  of 
acetate  of  ammonia,  or  sugar  of  lead. 

43 


338  DISEASES    OP    THE    EYES. 

1119.  In  the  acute  stage  of  conjunctivitis,  produced  by  general 
causes,  especially  when  attended  with  pain,  as  is  always  the  case 
where  the  sclerotica  becomes  involved,  cold  often  aggravates  this 
symptom,  and  in  that  case  tepid  or  warm  applications  always 
afford  relief.     The  best  of  these  are  fomentations  with  warm 
water,  or  a  decoction  of  the  leaves  or  heads  of  the  poppy  ;  they 
should  be  applied  till  relief  is  afforded,  and  then  discontinued. 
Warm  poultices  sometimes  relieve  the  pain  ;  but  we  cannot  re- 
commend their  use.     If  the  inflammation  has  a  tendency  to  ex- 
tend to  the  cornea,  the  disposition  of  this  part  to  take  on  inflam- 
mation is  promoted  by  these  applications,  and  we  fully  concur 
with  Dr.  Vetch,  that  the  relief  they  afford  is  in  the  highest  pos- 
sible degree  treacherous ;  and  that  so  obvious  is  their  tendency 
to  afford  relief,  by  accelerating  the  destruction  of  the  cornea, 
that  a  patient  should  be  entitled  to  recover  damages  in  whom 
the  disease  had  terminated  unfavourably,  whenever  it  has  done 
so  under  the  application  of  a  poultice.* 

1120.  There  are  periods  in  inflammation  of  the  conjunctiva  in 
which  stimulants  have  been  used  with  advantage.      The  first  is 
in  the  forming  stage,  or  where  there  is  only  simple  engorgement 
of  the  vessels.     The   Hindoos  apply  lime-juice  and  powerful 
astringents;  and  in  other  warm  latitudes,  where  the  disease  pre- 
vails, the  natives  generally  squeeze  some  pungent  vegetable  juice 
into  the  eye  on  the  first  attack.     Mr.  Vetch  acknowledges  that 
these  remedies  are  hazardous,  and  recommends  the  liquor  plumbi 
acetatis,  in  its  undiluted  state,  as  an  application,  "  the  most  effi- 
cacious, and  at  the  same  time  incapable  of  doing  harm  in  this 
and  every  stage  of  purulent  ophthalmia.     The  sensation  it  occa- 
sions is  that  of  some  sand  or  dust  having  got  into  the  eye,  which 
lasts  from  ten  to  twenty  minutes ;  there  is  generally  a  copious 
lachrymation,  and  the  eye  afterwards  feels  cool,  and  the  sight 
clear,  "t    Some  practitioners  highly  extol  the  solution  of  nitrate 
of  silver,  which  they  use  very  strong,  (ten  grains  to  the  ounce,) 
and  they  say  with  the  most  decided  advantage.     We  cannot 
however,  but  esteem  all  these  remedies  as  hazardous  at  the  com- 
mencement of  acute  conjunctivitis,  because,  it  is  extremely  diffi- 
cult often  to  decide  the  limits  between  simple  engorgement  and 
inflammation;  and  if  the  latter  be  mistaken  for  the  former,  the  pro- 
gress of  the  disease  will  be  accelerated,  and  its  violence  greatly 
augmented.     Hence,  though  when  timely  applied,  these  reme- 
dies are  useful,  when  there  can  be  any  doubts  on  the  subject 
they  should  never  be  employed. 

1121.  After  the  violence  of  inflammation  has  been  subdued, 
the  utility  of  these  remedies  are  undoubted.     One  of  the  best  is 

*  Op.  Cit.  p.  40.  f  Ib.  p.  205. 


DISEASES    OF    THE    EYES.  339 

the  nitrate  of  silver,  and  we  have  found  the  solution  of  one  or  two 
grains  to  the  ounce  of  sufficient  strength  ;  some  practitioners 
however,  recommend  a  solution  of  ten  grains  to  the  ounce,  but 
we  have  never  ventured  upon  so  strong  a  solution. 

1 122.  Dr.  Varlez,  of  the  Military  Hospital  of  Brussels  recom- 
mends the  chloruret  of  the  oxide  of  calcium,  in  solution,  from  one 
scruple  to  four  drachms,  to  an  ounce  of  distilled   water.     Mr. 
Gutnrie  has  also  used  it  in  several  cases  treated  at  the  Royal  West- 
minster Infirmary  for  Diseases  of  the  Eye,  with  advantage.*  We 
have  had  only  one  opportunity  of  trying  it,  in  the  Pennsylvania 
Infirmary  for  Diseases  of  the>  Eye,  but  in  that  one  we  were  much 
pleased  with  its  effects. 

1123.  The  solutions  of  the  sulphate  of  zinc,  the  acetate  of  zinc, 
the  sulphate  of  copper,  the  acetate  of  lead,  &c.  have  been  recom- 
mended, and  we  have  sometimes  employed  them  with  advan- 
tage.    The  best  mode  of  applying  all  these  solutions,  is  to  sepa- 
rate the  lids,  and  to  inject  them  into  the  eye  by  means  of  a  small 
syringe. 

1124.  The  vinous  tincture  of  opium  has  been  highly  extolled 
by  the  late  distinguished  ophthalmic  surgeon,  Mr.  Ware,t  we 
have  not  however  been  satisfied  with  its  effects.     The  ordinary 
tincture  and  the  watery  solution  have  also  been  recommended, 
we  cannot  speak  of  their  value  from  experience. 

1125.  Mr.  Vetch,  highly  extols  the  infusion  of  tobacco;  he  says 
"  it  possesses  the  valuable  properties  of  acting  as  a  powerful  as- 
tringent, restraining  the  purulent  discharge,  and  diminishing  the 
osdema  or  external  swelling  of  the  palpebrae;  at  the  same  time 
that  its  narcotic  qualities  often  relieve  the  pain  and  the  perpetual 
watchfulness  which  the  largest  doses  of  opium  cannot  subdue. 
The  infusion  of  two  drachms  of  the  leaves  to  eight  ounces  of 
water  is  so  powerfully  astringent  as  to  corrugate  the  skin  of  the 
fingers  when  they  have  been  for  some  time  immersed  in  it.  The 
proper  time  for  the  remedy  is  at  night."    We  shall  not  attempt 
however  to  specify  all  the  stimulants  that  have  been  recom- 
mended, their  number  being  almost  infinite ;  the  preceding  will 
perhaps  be  sufficient 

Treatment  of  Chronic  Conjunctivitis. 

1126.  When  the  inflammation  of  the  conjunctiva  is  mild  from 
the  commencement,  or  assumes  a  chronic  character  on  the  sub- 
sidence of  the  acute  stage,  a  treatment  somewhat  different  from 

•  American  Journal  of  the  Medical  Sciences,  Vol.  I.  p.  459. 
f  Remarks  on  the  Ophthalmy,  &c.  2d  edition,  p.  47. 


340  DISEASES    OF    THE    EYES. 

that  which  we  have  just  recommended  will  be  required.  Vene- 
section here  will  seldom  be  demanded  and  never  to  the  extent 
advised  in  the  acute  stage.  Topical  depletion  by  cups  or  leeches, 
will  be  found  much  more  serviceable,  but  even  this  remedy  will 
not  always  be  necessary.  Purgatives,  blisters  behind  the  ears, 
to  the  back  of  the  neck,  to  the  arm  or  leg,  are  kept  discharging; 
or  a  seton  to  the  neck ;  pediluvias,  and  light  diet,  should  con- 
stitute the  general  remedies. 

1127.  The  stimulating  applications,  as  the  solution  of  nitrate 
of  silver,  sulphate  of  copper  or  zinc,  alum  curd,  &c.  will  be  found 
here  eminently  serviceable.     Dr.  Physick,  some  years  ago  was 
induced  to  try  the  tar  water,  in  a  case  which  resisted  the  usual 
remedies,  and  with  the  most  complete  success.     The  vapour  of 
the  spirit  of  turpentine  has  been  recommended  ;  in  one  case  we 
believe  it  to  have  been  serviceable;  the  mode  of  applying  it  is  to 
hold  the  eyes  over  a  saucer  or  plate  containing  some  of  this 
fluid.     Care  will  however,  be  required,  both  in  the  use  and  se- 
lection of  local  remedies.    When  they  seem  to  aggravate  the  in- 
flammation, they  must  be  abandoned  and  antiphlogistics  exclu- 
sively used.     When  one  of  these  local  applications,  however,  is 
of  no  service  another  will  often  succeed,  and  it  is  also  useful 
to  change  the  remedy  when  it  seems  to  lose  its  power;  and  it 
may  after  a  time  be  again  recurred  to. 

Treatment  of  Conjunctivitis  in  New-born  Children. 

1128.  In  new-born  children  venesection  is  not  demanded;  de- 
pletion may  be  effected  by  means  of  two  or  three  leeches  to  each 
temple.     The  bowels  must  be  kept  freely  open  by  magnesia 
alone  or  combined  with  rhubarb ;  cold  applications  must  be  used 
externally,  and  the  eye  frequently  washed  with  tepid  milk  and 
water.     After  the  violence  of  the  inflammation  has  been  thus 
subdued,  a  solution  of  nitrate  of  silver  or  sulphate  of  zinc,  or  of 
alum,  should  be  injected  frequently  between  the  lids,  by  means 
of  a  small  syringe,  and  the  lids  prevented  from  adhering  and 
confining  the  secretion  by  frequently  washing  them.     It  is  of 
great  importance  to  attend  to  this  direction,  as  when  the  lids  be- 
come adherent  great  irritation  is  caused  by  the  force  however 
small,  used  to  separate  them,  as  well  as  by  the  distention  caused 
by  the  accumulation  of  the  secretion.     The  eye  should  therefore 
be  cleaned  every  half  hour  or  oftener,  and  this  direction  is  equally 
important  to  be  attended  to  in  adults. 

1129.  When  sloughing  of  the  cornea  takes  place,  the  sulphate 
of  quinine  must  be  given,  but  if  the  early  stage  is  properly  treated, 
this  will  rarely  if  ever  happen. 


DISEASES   OP    THE    EYES.  341 

1130.  When  the  disease  subsides  more  or  less  opacity  of  the  t 
cornea  is  generally  left,  which  must  be  treated  in  the  manner 
we  shall  point  out  in  the  section  on  diseases  of  that  coat. 

Treatment  of  Irritable  Conjunctivitis. 

1131.  In  the  acute  stage  the  inflammation  must  be  subdued  by 
topical  depletion  and  mild  purges.    Venesection  is  generally  in- 
jurious.    The  best  purge  is  in  the  first  instance,  cream  of  tartar 
and  sulphur,  and  afterwards  rhubarb  and  prepared  chalk  in  equal 
parts,  given  daily  or  twice  a  day,  so  as  to  produce  two  evacua- 
tions in  the  twenty-four  hours.     It  will  be  proper  to  continue 
the  latter  purgative  with  occasional  intermissions  during  the 
principal  course  of  the  disease.     Blisters  behind  the  ears,  to  the 
back  of  the  neck,  or  to  the  arm  or  leg  will  also  be  required. 
When  there  is  much  pain  or  spasms  of  the  orbicular  muscles, 
fomentations  of  decoction  of  poppy-heads,  or  of  boiling  water, 
with  a  little  laudanum  in  it,  will  usually  afford  relief,  in  other 
cases,  local  applications  in  this  stage  are  of  little  or  no  service. 

1132.  After  the  acute  inflammation  has  been  subdued  stimu- 
lants are  proper,  and  we  have  found  most  advantage  from  the 
red  precipitate  ointment,  which  should  be  prepared  fresh  and  the 
precipitate  very  finely  powdered;  if  the  ointment  be  not  well 
made  the  practitioner  will  be  often  disappointed  in  its  effects. 
This  ointment  should  be  softened  by  being  held  near  a  candle  or 
fire,  and  a  small  portion  rubbed  upon  the  edges  of  the  eyelids 
every  night.     The  vinum  opii,  and  a  watery  solution  of  opium, 
have  been  recommended,  but  we  have  never  resorted  to  them, 
having  been  always  satisfied  with  the  effects  of  the  ointment. 

1133.  The  child  should  be  kept  in  a  large  airy  apartment, 
moderately  lighted ;  and  only  the  lightest  and  most  easily  diges- 
tible food  allowed.     We  cannot  speak  in  terms  of  reprobation 
too  strong,  of  bandages  to  the  eyes,  or  even  of  shades;  they  add 
to  the  irritation,  and  instead  of  relieving  the  intolerance  of  light, 
render  it  more  permanent. 

1134.  Advantage  it  is  said  will  sometimes  be  derived  from  the 
tonics,  the  best  of  which  are  the  mineral  acids.    We  have  never 
had  occasion  to  resort  to  them. 

1135.  The  disease  is  usually  obstinate  and  relapses  frequent. 
Often  the  patient  is  nearly  well,  when  from  some  neglect  of  the 
nurse,  orimprudence  of  the  child,  acute  inflammation  is  re-excited 
and  the  whole  course  of  treatment  is  to  be  gone  through  again. 

Treatment  of  Pustular  Conjunctivitis. 

1136.  If  we  are  fortunate  enough  to  see  the  patient  at  the  com- 


342  DISEASES   OF    THE    EYES. 

mencement  of  his  complaint,  we  may  often,  by  touching  the 
pustule  with  the  solid  nitrate  of  silver  or  a  strong  solution  of 
this  substance,  and  by  the  administration  of  a  smart  purgative, 
arrest  its  formation.  If  however,  considerable  inflammation 
exist,  topical  depletion  by  leeches,  and  the  administration  of 
purgatives  must  be  premised,  and  when  the  inflammation  has 
been  subdued  by  these  means,  the  nitrate  of  silver  may  be  ap- 
plied. Advantage  will  also  be  derived  from  the  application  of  a 
dilute  ointment  of  the  nitrate  or  super-nitrate  of  mercury,  every 
night  to  the  pustules,  as  recommended  by  Mr.  Ryall,* 

Foreign  Bodies  in  the  Eye. 

1137.  We  have  mentioned  these  as  among  the  causes  of  inflam- 
mation of  the  conjunctiva;  and  in  all  cases  they  should  be  care- 
fully searched  for,  and  removed;  since  so  long  as  they  continue 
in  the  eye  will  the  inflammation  be  kept  up.     Not  unfrequently 
the  disease  continues  for  months,  resisting  every  remedy,  when 
a  careful  examination  has  detected  some  foreign   body,  which 
being  removed,  the  complaint  has  been  promptly  relieved. 

1138.  As  some  difficulty  is  often  experienced  in  removing  these 
bodies,  the  following  observations  on  the  subject  may  be  inte- 
resting in  this  place. 

1139.  Foreign  bodies  entangled  in  the  eye,  occasion  great  pain, 
inflammation,  and  inability  to  move  the  lids.     They  excite  an 
additional  secretion  of  tears;  the  flow  of  which  frequently  re- 
moves them.     If  this  fail,  the  lids  should  be  held  open  by  the 
fingers,  the  patient  desired  to  look  towards  the  side  opposite  to 
that  wherein  the  extraneous  body  lies,  and  the  foreign  substance 
may  be  readily  removed  with  a  probe  or  a  small  roll  of  fine  linen. 
If  one  of  the  ciliae  fall  into  the  eye,  it  may  be  removed  in  the 
above  manner. 

1140.  Small  round  bodies,  such  as  beads,  usually  lie  beneath 
the  upper  eyelid,  and  are  got  out  by  laying  hold  of  that  eyelid 
by  its  cilise  and  margin,  drawing  it  outwards,  and  then  making 
the  patients  look  down,  or  while  the  eyelid  is  held  thus,  a  small 
curette  is  to  be  introduced  under  its  temporal  angle,  and  carried 
gently  on  towards  the  nose. 

1141.  If  the  bodies  be  very  small,  or  consist  of  dust  or  sand, 
they  should  be  washed  out  by  introducing  the  pipe  of  a  small 
syringe  beneath  the  eyelid  at  its  outer  angle,  and  then  directing 
the  stream  of  fluid,  which  should  be  tepid  water,  or  milk  and 
water,  over  the  eye,  towards  the  nose. 

*  Transactions  of  the  King  and  Queen's  College  of  Physicians  in  Ireland, 
Vol.  V. 


DISEASES    OP    THE    EYES.  343 

1 142.  Extraneous  particles  are  sometimes  insinuated  under  the 
upper  lid,  and  adhere  to  it.     In  these  cases,  it  is  necessary  to 
turn  the  inside  of  the  lid  outward,  and  this  may  be  done  with- 
out difficulty  by  the  following  means.   The  eyelashes  should  be 
taken  hold  of  with  the  forefinger  and  thumb  of  the  left  hand,  a 
slight  pressure  being  at  the  same  time  made  on  the  outside  of  the 
lid  a  little  above  the  upper  margin  of  the  tarsus,  with  the  end  of  a 
probe,  (or  some  similar  instrument,)  held  in  the  right  hand.  The 
part  being  thus  kept  down  by  the  instrument,  the  lid  may  be 
gently  raised  and  then  turned.     In  this  everted  position  of  the 
lid,  the  foreign  particle  is  immediately  brought  into  sight,  and, 
as  before  directed,  may  be  removed  with  a  probe  or  roll  of  fine 
linen,  &c.     When  the  particle  is  within  the  lower  lid,  this  may 
be  readily  drawn  down  so  as  to  bring  the  foreign  substance  into 
view,  and  it  may  be  removed  as  above  directed. 

1143.  Small  bodies,  such  as  particles  of  metal,  the  hard  wings 
of  insects,  &c.  are  sometimes  indented  in  the  conjunctiva;  a  piece 
of  fine  silver  wire,  beat  thin  and  fixed  in  a  handle,  will  be  found 
very  convenient  to  remove  them  with.  When  splinters  of  metal 
get  beneath  the  conjunctiva,  they  should  be  seized  with  a  pair 
of  forceps,  and  cut  out  with  a  pair  of  fine  scissors. 

1144.  Workmen  in  filing  or  turning  of  iron,  are  liable  to  have 
particles  from  it  to  fly  into  their  eyes.  These  particles  are  often 
imbedded  in  the  cornea.  They  should  be  removed  with  the  point 
of  a  cataract  needle,  or  a  common  thumb  lancet,  which  is  to  be 
introduced  close  to  the  body,  and  the  point  then  pressed  outwards. 
If  these  substances  are  allowed  to  remain,  suppuration  will  take 
place,  and  they  will  thus  be  separated  and  will  drop  out.     But 
we  should  not  trust  to  the  operation  of  nature  in  these  cases,  for 
the  continuance  of  these  foreign  substances  in  the  eye  will  gene- 
rally produce  violent  inflammation,  and  add  greatly  to  the  pa- 
tient's sufferings. 

1145.  Particles  of  cantharides,  pieces  of  mortar,  and  unslacked 
lime  should  be  removed  by  means  of  a  camel's  hair  pencil  dipped 
in  oil  or  butter. 

SECT.  II. — SCLEROTISIS. — INFLAMMATION  OF  THE  SCLEROTIC  A. 

Anatomical  Characters  of  the  Sclerotica. 

1146.  The  sclerotica  is  a  strong  membrane,  composed  of  firm, 
white,  tendinous  fibres,  intimately  interlaced,  and  consists  of  a 
single  lamina,  though  in  the  foetus  it  may  be  divided  into  two, 
these  however  subsequently  coalesce  so  firmly  as  not  to  admit  of 
separation.     Externally  it  is  covered  with  a  fine  cellular  tissue, 
which  connects  it  with  the  conjunctiva ;  its  internal  surface  is 


344  DISEASES   OF    THE    EYES. 

smooth  having  no  connexion  with  the  choroid  except  by  vessels 
and  nerves.  The  sclerotica  does  not  form  a  complete  sphere,  it 
is  deficient  at  its  anterior  part,  where  its  place  is  supplied  by  a 
peculiar  transparent  membrane  called  the  cornea.  This  was  con- 
sidered by  the  older  anatomists  as  a  continuation  of  the  former 
membrane,  and  the  name  of  opaque  cornea  was  given  it,  and  of 
transparent  cornea  to  the  latter.  We  shall  not  enter  into  the 
discussion  waged  in  relation  to  this  opinion,  and  which  has  been 
carried  on  with  all  that  warmth  usually  characteristic  of  disputes, 
where  the  difference  is  more  'about  words  than  realities ;  we  will 
merely  remark  that  the  structure,  functions,  and  pathological 
changes  effected  by  disease  in  the  two,  are  essentially  dif- 
ferent, and  that  therefore  in  a  pathological  view,  they  must  be 
considered  as  distinct.  The  optic  nerve  enters  the  sclerotica  at 
its  posterior  part;  the  posterior  ciliary  arteries  penetrate  it  around 
the  entrance  of  the  optic  nerve  ;  the  anterior  ciliary  arteries  and 
some  branches  from  the  vessels  of  the  conjunctiva,  pass  through 
foramina,  a  little  behind  the  cornea ;  and  the  veins  which  form 
the  vassa  vorticosa  of  the  choroid,  penetrate  it  obliquely  about 
its  middle.  It  is  of  importance  to  bear  in  mind  this  distribution, 
inasmuch  as  the  appearance  of  these  different  sets  of  vessels  in 
inflammation,  enables -us  to  distinguish  the  tissue  affected. 

Physiological  Characters. 

1147.  The  sclerotica  is  exceedingly  tough  and  firm,  but  is 
capable  of  considerable  extension,  as  is  shown  in  hydropthalmia, 
staphyloma  scleroticse,  and  fungus  haematodes,  and  it  appears 
also  to  possess  contractility,  as  it  collapses  when  the  water  in 
hydropthalmia  is  evacuated,  and  in  atrophy  of  the  eye. 

Pathological  Characters. 

1148.  In  its  diseases  as  well  as  in  its  structure,  the  sclerotica 
closely  resembles  the  other  fibrous  membranes,  the  fibrous  cap- 
sules, the  tendinous  sheaths  and  aponeuroses.     It  does  not  take 
on  inflammatory  action  very  readily,  though  inflammation  may 
be  excited  in  it,  and  when  once  produced,  is  obstinate  and  at- 
tended with  great  pain.  The  violence  and  duration  of  inflamma- 
tion, we  have  already  remarked,  appears  to  be,  cxteris  paribus, 
in  direct  proportion  to  the  resistance  opposed  to  the  distention 
of  the  vessels  affected  by  the  inflammatory  action.     This  resist- 
ance may  be  owing  to  the  tone  of  the  vessels  themselves,  the 
tension  of  the  surrounding  parts,  or  the  dense  nature  of  the 
tissue.  * 

*  Vetch.  A  Practical  Treatise  on  the  Diseases  of  the  Eye,  p.  9. 


DISEASES    OP    THE    EYES.  345 

1149.  Of  the  truth  of  the  law  we  have  mentioned,  a  beautiful 
illustration  is  afforded,  by  the  difference  in  the  symptoms  and 
progress  of  inflammation,  according  as  it  attacks  the  sclerotica 
or  conjunctiva.     The  latter  is  capable  of  great  distention  in  con- 
sequence of  its  lax  texture  and  the  looseness  of  its  cellular  tissue^ 
little  resistance  is  therefore  given  to  the  enlargement  of  its  ves- 
sels, they  soon  become  distended  with  red  blood  and  this  is  ac- 
companied with  little  pain,  their  tone  is  readily  exhausted,  and 
if  the  exciting  cause  does  not  continue  to  act,  they  quickly  fall 
into  a  varicose  state,  or  again  contract  to  their  original  dimen- 
sions. 

1150.  The  sclerotica  on  the  other  hand,  is,  as  we  have  ob- 
served, a  dense  membrane,  but  little  elastic,  and  offers  consider- 
able resistance  to  the  distention  of  its  vessels ;  this  opposition  to, 
their  rapid  and  easy  dilatation  prevents  their  tone  from  being 
speedily  exhausted,  they  remain  long  in  a  state  of  active  inflam- 
mation, and  this  is  always  attended  with  a  high  degree  of  pain, 
and  irritation.     The  inflammation  of  parts  tightly  bound  down 
by  tendinous  fascia,  exhibits  the  same  phenomena. 

1151.  Of  the  pathological  changes  which  take  place  in  the 
solerotica  when  inflamed,  we  have  no  very  accurate  or  precise 
information.    Like  the  other  fibrous  membranes,  it  seldom,  per- 
haps, never  suppurates,  and  coagulable  lymph  is  rarely  poured 
out  by  its  vessels.     Its  substance  sometimes  becomes  softer  and 
flaccid,  at  others  it  assumes  a  firmer  or  harder  texture,  and  in- 
stances have  occurred  of  its  becoming,  in  part,  ossified.*     It  oc- 
casionally becomes  thinner  by  intestinal  absorption,  and  bulges, 
out,  forming  a  staphyloma  scleroticae,t  and  in  some  instances  i$ 
is  thickened. 

Causes. 

1152.  Inflammation  of  the  sclerotica  is  said  to  be  excited  by 
various  mechanical  and  chemical  stimuli,  f  such  as  blows,  punc- 
tures, the  lodgment  of  extraneous  irritants  on  the  surface  or  im- 
bedded in  the  conjunctiva,  and  more  especially  when  applied  to 
the  cornea ;  acrid  fumes,  excessive  application  of  the  eye,  or  its 
exposure  to  great  heat  or  reflected  light,  the  irritation  from  a 
granular  state  of  the  palpebral  conjunctiva,  &c.  these  are,  how- 
ever, we  believe,  far  from  being  very  frequent  causes  of  the  dis- 
ease ;  on  the  contrary,  primary  sclerotitis  is  rarely  produced  by 
them.     Extension  of  inflammation  from  the  conjunctiva,  which 
is  supposed  to  be  the  most  common  cause  of  inflammation  of  the 

*  Wardrop,  Morbid  Anatomy  of  the  Human  Eye,  Vol.  II.  p.  240. 
f  Travers,  Synopsis  of  the  Diseases  of  the  Eye,  p.  130. 
i  Vetch,  o.  c.  p,  23. 

44 


346  DISEASES    OF    THE    EYES. 

sclerotica,  is,  we  suspect,  an  occurrence  by  no  means  frequent. 
In  violent  conjunctivitis,  especially  after  it  has  existed  some 
time,  the  ciliary  vessels  which  pass  over  the  surface  of  the 
sclerotica  to  the  anterior  part  of  the  globe,  may  often  be  per- 
ceived enlarged,  and  can  be  seen  beneath  the  conjunctiva,  ad- 
vancing towards  the  cornea  in  distinct  trunks,  seldom  anasto- 
mosing until  they  arrive  near  the  cornea,  around  the  margin  of 
which  they  ramify  and  anastomose,  and  form  a  peculiar  red 
zone.  We  are  persuaded  that  this  has  led  to  the  hasty  inference 
that  the  inflammation  has  extended  to  the  sclerotica. 

1153.  Inflammation  of  the  conjunctiva  is  more  frequently  pro- 
pagated to  the  iris  and  internal  tissues,  than  to  the  sclerotica ; 
this  last  membrane,  as  we  have   already  remarked,  does  not 
readily  take  on  inflammatory  action;  its  vessels,  moreover,  have 
less  frequent  and  direct  communication  with  those  of  the  con- 
junctiva than  the  vessels  of  the  latter  have  with  those  of  the  in- 
ternal tissues.     Inflammation  is.not,  however,  propagated  with 
facility,  from  the  conjunctiva  to  the  iris  or  choroid.     The  dense 
and  unyielding  nature  of  the  sclerotica,  prevents  the  vessels 
which  pass  through  it  to  these  membranes  from  readily  enlarging, 
and  hence  the  anterior  ciliaries  may  be  distended  without  the 
inflammatory  action  being  transmitted  to  the  internal  tissues.   In 
fact,  the  structure  of  the  sclerotica  is  such  as  to  enable  it  to  per- 
form the  offices  for  which  it  was  destined  in  the  most  perfect 
manner;  dense  and  firm  in  its  structure,  it  maintains  the  globular 
figure  of  the  ball,  preserves  and  supports  its  delicate  internal 
tissues,  it  prevents  the  vessels  passing  through  it  from  dilating 
when  acted  on  by  slight  or  transient  irritations,  and  itself  not 
readily  taking  on  inflammation,  remains  uninjured,  often  when 
in  contact  with  a  highly  inflamed  and  suppurating  membrane. 

1154.  Another  opinion,  which  w>  believe  to  be  equally  erro- 
neous, is  almost  universally  entertained;  it  is,  that  inflammation 
or  ulceration  cannot  take  place  in  the  cornea,  until  inflammatory 
action  has  first  been  excited  in  the  sclerotic  coat,  and  that  there- 
fore irritation  or  wounds  of  the  cornea  always  produce  sclerotitis. 
Inflammation  may  however  exist  in  the  cornea,  and  proceed  to 
the  effusion  of  coagulable  lymph,  and  even  small  ulcers  occur 
without  any  red  vessels  being  visible  either  in  this  coat  or  in  the 
sclerotic;  and  when  they  do  present  themselves,  they  appear  to 
belong  to  a  more  superficial  series  than  those  of  the  sclerotica. 
The  existence  of  ulcers,  previous  to  any  red  vessels  being  appa- 
rent, no  doubt  led  to  the  opinion  entertained  by  Scarpa,  that  the 
inflammation  was  produced  by  the  ulcers,  instead  of  the  latter 
by  the  former,  as  is  more  generally  and  correctly  believed. 

1155.  Inflammation  of  the  sclerotica  is  generally  accompanied 
with  inflammation  of  the  fibrous  capsules  and  aponeuroses,  com- 


DISEASES    OP    THE    EYES.  347 

monly  called  rheumatism,  and  is  usually  produced  either  by  me- 
tastasis of  the  affection  of  these  parts,  or  is  excited  by  the  same 
causes  that  produce  inflammation  in  them,  among  which  cold  is 
the  most  common.  It  most  frequently  occurs  in  the  spring  or 
fall,  particularly  in  the  former,  and  may  be  often  traced  to 
exposure  to  cold  or  sudden  vicissitudes  of  temperature. 

1156.  From  the  great  resemblance  between  gout  and  rheuma- 
tism, it  might  be  supposed  that  the  former  disease  would  also  pro- 
duce sclerotitis,  and  we  have  no  doubt  that  such  is  the  case, 
though  we  have  never  met  with  such  an  occurrence. 

1157.  We  have  stated  gonorrhrea  to  be  one  of  the  causes  of  in- 
flammation of  the  conjunctiva;  it  is  a  very  curious  fact,  if  true  as 
stated,  that  it  is  also,  and  perhaps  more  frequently,  a  cause  of  inflam- 
mation in  the  sclerotica.  The  credit  of  being  the  first  to  notice  this 
circumstance,  appears  due  to  Dr.  Vetch,  whose  excellent  treatise 
on  the  diseases  of  the  eye  we  have  often  had  occasion  to  quote. 

1158.  We  are,  however,  inclined  to  the  belief,  and  the  cases 
given  by  Dr.  Vetch  would  fully  warrant  such  a  conclusion,  that 
they  are  rather  concomitant  affections,  both  produced   by  the 
same  cause,  than  that  the  sclerotitis  is  the  consequence  of  the 
metastasis  of  the  inflammation  of  the  urethra.*     In  all  the  cases 
narrated  by  Dr.  Vetch,  the  discharge  from  the  latter  membrane, 
instead  of  being  suppressed  when  the  former  became  affected, 
became  more  violent  as  the  disease  progressed  in  it;  the  two  in- 
flammations advancing pari passu,  and  when  the  one  abated  the 
other  decreased  also.t 

1159.  The  existence  of  a  catarrhal  inflammation  of  the  urethra, 
as  it  has  been  called,  is  now  generally  admitted;  and  its  existence 
is  more  frequent  than  Is  usually  supposed.     We  have  repeatedly 
seen  it  follow  connexion,  when  there  was  every  reason  to  believe 
the  woman  entirely  free  from  disease;  and,  in  most  instances, 
the  patients  acknowledged  that  they  had  over-exerted  their  se- 
minal and  muscular  systems;  they  were  generally  aware  of  having 
subsequently  exposed  themselves  to  cold,  and  were  also  some- 
times affected  with  other  catarrhal  or  rheumatic  affections.   Now, 
these  are  the  very  cases,  as  is  stated  by  Dr.  Vetch,  in  which  the 
inflammation  of  the  sclerotica  occurs.     In   Dr.  Vetch's  cases, 
there  was  also  inflammation  of  the  conjunctiva,  with  puriform 
discharge,  and  this  combination  is  perhaps  frequent. 

1160.  Inflammation  of  the  sclerotica  also  occurs  conjointly 
with  that  form  of  rheumatism  which  is  denominated  syphilitic, 
and  is  the  effect  either  of  a  metastasis,  or  it  is  generated  by  the 
same  cause  which  produces  the  latter  affection. 

•  Dr.  Vetch  expresses  his  suspicions  of  this  being  the  case,  Op.  Cit.  p.  248. 
f  Op.  Cit.  p.  248. 


348  DISEASES    OF    THE    EYES. 

1161.  When  conjoined  with  the  different  affections  we  have 
noticed,  these  are  considered  as  the  cause  of,  and  are  supposed 
to  impress  upon  the  inflammation  of  the  sclerotica  their  own 
distinctive  characters.     Mr.  Wardrop,  in  his  excellent  paper  on 
"  Rheumatic.  Ophthalmia,"*  remarks,  "  there  are  other  kinds  of 
inflammation  which  derive  their  character,  not  from  the  pecu- 
liarity of  the  texture  inflamed,  but  from  being  produced  from 
specific  virus,     ttence,  the  gonorrheal,  the  syphilitic,  the  scro- 
fulous, the  gouty,  and  the  rheumatic  inflammations  of  the  eye; 
all  of  which  are  accompanied    with  symptoms   different  from 
those  of  simple  inflammation  of  any  of  the  textures  which  com- 
pose that  organ." 

1162.  In  what  this  "  specific  virus"  consists,  or  where  or  how 
it  is  generated,  we  confess  that  we  have  never  been  able  to  dis- 
cover.   The  attempts,  made  to  indicate  the  peculiar  appearances 
which  each  virus  is  supposed  to  stamp  upon  the  inflammation  it 
produces,  have  wholly  failed,  and  the  candid  must  acknowledge 
that  they  know  of  no  phenomena  by  which  they  can  be  distin- 
guished.    What  benefit,  then,  is  to  be  derived  from  this  separa- 
tion and  multiplication  of  species — this  barren  parade  of  names  ? 
The  real  difference  between  the  inflammations  of  the  eye  depends 
upon  the  tissue  affected,  and  the  modifications  of  the  inflamma- 
tion of  each  tissue  is  dependent  upon  the  diathesis  or  constitution 
of  the  patient. 

1163.  Cold  is  the  most  common  cause  of  inflammation  of  the 
sclerotica,  and  the  variations  which  the  disease  may  display  in 
different  individuals  results  from  the  dissimilarities  of  their  con- 
stitutions or  diathesis.     If  the  affection  is  produced  by  other 
causes,  as  extension  of  inflammation  from  contiguous  parts,  or 
by  mechanical  injuries,  &c.  the  same  phenomena  result.     The 
activity  of  the  causes  or  the  extent  to  which  it  is  applied,  may 
caeteris  paribus,  influence  the  violence  of  the  inflammation,  but 
the  peculiarities  of  the  patient  exercise  a  marked  and  evident 
controul  over  the  effect  of  all  exciting  causes.!     Thus,  the  most 
violent  local  inflammation  may  be  excited  in  an  individual  by  a 
certain  cause,  and  the  same  cause  acting  upon  another  under  pre- 
cisely similar  circumstances,  and  in  a  similar  manner,  may  ex- 
cite in  him  a  slight  inflammation,  or  perhaps  produce  no  preju- 
dicial consequences ;  or,  if  the  cause  has  acted  upon  the  system 
generally,  disease  in  another  and  quite  dissimilar  tissue. 

*  Medico-Chirurgical  Transactions,  Vol.  X.  p.  2. 

f  Mr.  Wardrop  says  that  "  rheumatic  ophthalmia,"  (sclerotitis,)  "not  unfre- 
quently  follows  the  operations  for  Cataract,  particularly  in  patients  who  have 
fead  rheumatism  in  other  parts  of  the  body.  Rheumatism  is  frequently  observed 
to  attack  a  joint  or  part  that  has  been  injured." 


DISEASES    OF    THE    EYES.  349 


Symptoms. 

1164.  Inflammation  of  the  selerotiea  is  very  variable  in  its 
mode  of  attack,  and  irregular  in  its  progress.   Sometimes  it  comes 
on  suddenly,  is  of  a  very  violent  character,  and  attains  its  height 
in  a  short  time;  at  others,  it  is  of  a  more  insidious  nature,  slow 
in  its  progress,  involving  the  internal  tissues  in  its  disease,  and 
producing  considerable  mischief,  while  the  practitioner  is  thrown 
off  his  guard  by  its  indolent  and  shifting  character. 

1165.  When  it  assumes  an  acute  form,  it  usually  attacks*  sud- 
denly, and  commences  with  pain  and  redness  of  the  eye,  accom- 
panied with  some  degree  of  pyrexia.     The  pain,  as  regards  its 
violence,  is  exceedingly  variable;  sometimes  it  is  excruciating. 
We  have  been  told  by  patients,  "  if  you  do  not  afford  us  speedy 
relief,  we  shall  go  crazy;"  at  others,  it  is  moderate;  occasionally 
it  intermits,  but  generally  it  is  unceasing,  though  undergoing; 
exacerbations,  which  are  usually  most  severe  at  night.  The  pain 
is  generally  seated  in  the  eyeball,  but  extends  itself  also-  to  the 
temple>  the  brow,  the  cheek-bone,  the  teeth,  or  even  the  whole 
head ;  sometimes  it  is  confined  to  one  side  of  the  head ;  occasion- 
ally there  is  severe  pain  in  the  ear  or  cavity  of  the  nose;  and  it 
is  often  accompanied  with  rheumatic  pains  in  other  parts  of  the 
body. 

1166.  The  sclerotiea  is  more  or  less  reddened,  occasioned  by 
the  ramifications  of  minute  vessels,   which  present  a  peculiar 
carmine  or  rose-red  colour.*    They  are  equally  numerous  on  its 
posterior  and  anterior  portion,  and  run  in  nearly  straight  lines 
to  the  very  verge  of  the  cornea. 

1167.  There  is  generally  very  profuse  lachrymation,  though 
occasionally,  especially  at  the  commencement  of  the  disease,  the 
secretion  of  tears  is  suppressed. 

1168.  The  pupil  is  often  contracted,  but  preserves  its  circular 
form  and  thin  flowing  edge ;  its  colour,  especially  that  of  its 
inner  circle,  is  in  this  case  rather  lighter  than  natural;  this  af- 
fection of  the  iris  we  believe  to  be  entirely  sympathetic. 

1169.  There  is  often  intolerance  of  light,  but  this  symptom 
does  not  always  occur,  as  is  supposed  by  many  writers. 

1170.  The  tongue  is  frequently  furred,  and  the  gastric  and 
biliary  organs  deranged. 

1171.  If  the  disease  is  very  violent,  or  continues  for  any  great 
length  of  time,  the  inflammation  may  extend  itself  to  the  inter- 
nal tissues ;  this  is  manifested  by  a  red  zone  round  the  cornea, 

*  We  believe,  however,  that  inflammation  of  this  membrane,  as  well  as  of 
the  cornea,  may  exist  without  any  red  vessels  being  visible. 


350  DISEASES    OP    THE    EYES. 

by  the  iris  becoming  irregular,  the  pupil  filled  by  portions  of 
coagulable  lymph  and  the  other  symptoms  of  iritis;  sometimes 
the  choroid,  retina,  and  hyaloid  membranes  suffer;  the  vitreous 
humour  becomes  more  or  less  opaque,  and  vision  is  impaired  or 
even  destroyed ;  if  the  disease  is  not  arrested,  hydropthalmia 
may  be  superadded.*  The  conjunctiva,  particularly  that  portion 
which  covers  the  cornea,  not  unfrequently  participates  in  the 
inflammation;  it  loses  its  transparency;  small  watery  vesicles 
form,  which  burst,  leaving  small  ulcers;  these  seldom  extend 
deep  into  the  cornea,  and  rarely  leave  cicatrices  behind,  but 
generally  little  pits  or  irregularities  only,  which  soon  fill  up  in 
healthy  people:t  occasionally,  however,  the  ulcers  penetrate  the 
cornea,  staphyloma  or  prolapsus  iridis  is  formed,  or  the  contents 
of  the  globe  are  discharged. 

Diagnosis. 

1172.  Inflammation  of  the  sclerotica  may  be  distinguished 
from    iritis    by  the   following  marks: — The  blood-vessels  are 
equally  numerous  over  the  whole  sclerotica,  while  in  iritis  they 
are  most  numerous  on  its  anterior  part,  where  they  anastomose' 
very  frequently,  and  form  a  peculiar  red  zone.      In  the  former 
disease  they  advance  to  the  very  verge  of  the  cornea,  while  in 
the  latter,  they  terminate  abruptly  about  a  line  behind  it,  leav- 
ing a  distinct  pale  circle,  which  is  not  seen  in  the  former  disease, 
or  but  rarely,  and  then  it  is  not  very  evident.     In  the  former, 
too,  the  redness  will  on  close  examination,  be  found  to  be  pro- 
duced more  by  minute  ramifications  than  by  large  trunks,  as  is 
the  case   in    the   latter.     The  iris,  though  contracted  in   the 
former  disease,  does  not  lose  its  circular  form,  or  its  thin  flow- 
ing edge,  and  become  puckered  and  thickened  as  in  the  latter, 
nor  does  it  exhibit  any  other  change  in  its  appearance,  except 
becoming  a  little  paler.     When  examined,  the  eye  will  be  found 
more  steady  in  the  former,  and  will  not  roll  incessantly  as  in  the 
latter  affection. 

1173.  Sclerotitis  may  be  distinguished  from  conjunctivitis,  by 
the  absence  of  puriform  discharge,  and  by  the  eyelids  not  being 
affected :  by  the  vessels  being  of  a  rose-red  or  carmine  colour, 
running  in  nearly  straight  lines,  and  being  deep-seated;  while 
in  the  latter  disease  they  are  darker,  very  tortuous  and  super- 
ficial. 

*  Mr.  Wardrop  says,  that  in  two  instances  he  "  observed  a  quantity  of  thick, 
puriform  fluid  had  formed  in  the  posterior  chamber,  and  burst  through  the 
sclerotic  coat." 

f  A  Manual  of  the  Diseases  of  the  Human  Eye,  &c.  by  Dr.  C.  H.  Weller. 
Translated  by  G.  C.  Monteith,  M.  D.  Glasgow,  1821.  Vol.  II.  p.  217. 


DISEASES   OP   THE    EYES.  351 


Treatment. 

1174.  Blood-letting,  as  may  be  supposed,  is  a  very  important 
remedy  in  this  complaint.  Mr.  Wardrop,  however,  is  of  opinion 
that  patients  affected  with   rheumatic    ophthalmia  cannot  bear 
bleeding  to  a  great  extent,  that  the  remedy  should  therefore  be 
employed  with  moderation,  and  that  the  little  relief  afforded  by 
it  in  this  disease,  may  be  regarded  as  one  of  its  diagnostic  cha- 
racters.*    Our  experience  has  led  us  to  very  opposite  conclu- 
sions: we  believe  that  patients  in  this  complaint  bear  depletion 
very  well,  that  it  should  be  employed  freely,  and  that  the  relief 
afforded  by  it  is  striking;  blood-letting  in  fact,  is  usually  one  of 
the  first  remedies  demanded.     The  quantity  to  be  drawn  must 
of  course  be  determined  by  circumstances;  we  usually  detract 
blood  as  long  as  the  pain  continues  violent,  unless  the  pulse 
should  counterindicate  it.     The  most  convenient  way  is  to  take 
blood  from  the  arm;  opening  the  temporal  artery  has  no  ad- 
vantage  over   venesection.      Even   after   as    much    blood    has 
been  taken  as  can  be  safely  detracted  in  this  way,  topical  de- 
pletion by  cups  may  be  practiced  with  great  advantage;  it  may 
be  used  even  earlier  than  this  with  benefit,  but  until  the  activity 
of  the  pulse   has  been  reduced   by  general  depletion,   topical 
bleeding  has  no  advantages  over  general.     We  prefer  cups  to 
leeches,  the  irritation  produced  by  the  latter  to  the  delicate  organ 
of  vision,  often  causing  more  injury  than  the  depletion  does 
good;  we  have  seen,  especially  in  conjunctivitis,  the  inflamma- 
tion exceedingly  aggravated  by  them;  if  there  are  any  cases  in 
which  they  are  preferable  to  cups,  it  is  where  the  violence-ef  the 
inflammation  has  abated,  or  where  there  is  a  chronic  distention 
of  the  vessels;  perhaps  under  these  circumstances  they  unload 
the  vessels  more  promptly. 

Purgatives. 
\ 

1175.  As  co-operating  to  the  same  end,  namely,  the  lessening 
the  quantity  of  the  circulating  fluid,  purgatives,  particularly  the 
neutral  salts,  will  be  found  highly  useful.     When  the  disease 
under  consideration,  is  accompanied  with  disorder  of  the  biliary 
organs,  calomel  alone,  or  combined  with  rhubarb,  and  its  opera- 
tion promoted  by  senna  and  manna;  or  the  Epsom  salt,  and  cal- 
cined magnesia;  or  the  blue  pill  at  night,  with  magnesia  the  next 
morning,  should  be  preferred. 

*  Meclico-Chirurgical  Transactions,  Vol.  X.  p.  13. 


352  DISEASES    OF    THE    EYES. 


Diaphoretics. 

1176.  The  nature  of  the  exciting  cause  would  at  once  suggest 
the  propriety  of  diaphoretics  in  this  complaint.     In  the  early 
stages,  where  the  skin  is  hot  and  dry,  and  the  pulse  not  suffi- 
ciently reduced,  the  nitrous  powders,  (calomel,  nitre,  and  tartar 
emetic,)  see  p.  115,  will  be  found  most  useful.     As  fulfilling 
two  indications,  evacuating  the  bowels,  and  determining  to  the 
surface,  advantage  will  be  derived  from  the  saline  mixture,  see 
p.  115,  or  from  the  combination  of  one  grain  of  tartar  emetic, 
to  an  ounce  of  the  Epsom  salt. 

1177.  Later  in  the  disease,  or  where  it  has  ab  origine  as- 
sumed a  less  febrile  character,  and  in  chronic  cases,  the  Dover's 
powder  given  at  night,  will  be  found  highly  useful. 

1 178.  In  the  latter  cases,  also,  we  have  found  the  most  striking 
benefit  from  the  sarsaparilla;  it  may  be  given  in  decoction  or 
extract,  the  former  we  usually  employ.     The  corrosive  subli- 
mate may  be  given  at  the  same  time  in  doses  of  from  one-tenth 
to  one-eighth  of  a  grain ;  the  mode  in  which  we  administer  it,  is 
to  dissolve  two  grains  in  one  drachm  of  alcohol,  and  then  add 
eight  ounces  of  distilled  water;  a  table-spoonful  of  this  to  be 
added  to  a  wine-glassful  of  the  decoction  of  sarsaparilla,  and  to 
be  taken  three  or  four  times  a  day ;  the  decoction  alone  to  be 
drunk  very  freely  during  the  intervals.     The  tartar  emetic  may 
sometimes  be  substituted  for  the  corrosive  sublimate,  and  in  simi- 
lar doses. 

1179.  We  direct  the  decoction  of  sarsaparilla  to  be  made  in  the 
following  manner ;  one  ounce  and  a  half  of  the  root  of  sarsapa- 
rilla, bruised,  two  drachms  of  the  bark  of  the  root  of  sassafras, 
and  we  sometimes  add  two  drachms  of  the  wild  cherry-tree  bark, 
and  occasionally  the  same  quantity  of  the  shavings  of  guaiacum 
wood,  to  be  put  into  a  quart  of  water,  and  boiled  down  to  three 
half  pints.* 

1180.  We  have  used  this  also,  in  some  exceedingly  obstinate 
cases  of  chronic  rheumatism,  affecting  the  fibrous  tissues  gene- 
rally, with  the  most  pleasing  results. 

1181.  A  very  striking  instance  of  the  benefit  derived  from  this 
remedy,  is  furnished  in  the  case  of  Henry  Johnson,  a  coloured 
man,  aged  thirty-five,  who  applied  at  the  Infirmary,  March  8, 
1824;  he  informed  me  that  he  had  been  attacked  about  two  years 
before,  in  consequence  of  taking  cold,  that  he  had  been  under  the 

*  The  concentrated  compound  syrup  of  sarsaparilla,  manufactured  by  Mr. 
Charles  Marshall,  of  this  city,  we  have  found  to  be  an  excellent  prepara- 
tion. 


DISEASES    OF    THE    EYES.  353 

care  of  several  physicians,  and  had  taken  various  remedies,  with 
little  Or  no  advantage  ;  he  had  become  exceedingly  emaciated, 
was  incapacitated  for  labour,  and  had  not,  he  assured  me,  en- 
joyed one  night's  uninterrupted  or  quiet  sleep  for  eighteen 
months.  There  was  but  slight  redness  of  the  sclerotica,  the  pain 
not  very  violent  during  the  day,  but  severe  at  night,  and  ac- 
companied with  great  restlessness;  the  pulse  was  quickened,  but 
with  little  tenseness,  and  rather  smaller  than  natural.  We  purged 
him  for  a  few  days  with  cremor  tartar  and  sulphur,  and  then  put 
him  upon  the  decoction  of  sarsaparilla  and  corrosive  sublimate: 
in  about  three  weeks  he  was  discharged  perfectly  cured. 

1182.  Notwithstanding  the  fact  that  the  state  of  the  system  pro- 
duced by  the  action  of  mercury,  predisposes  the  fibrous  mem- 
branes to  inflammation,  it  will  be  found  when  administered  with 
due  caution  to  be  productive  of  the  most  beneficial  effects  in  this 
complaint;  its  usefulness  is  however  less  striking  than  in  iritis, 
but  its  administration  is  often  not  less  indispensable.  One  of  the 
most  remarkable  characters  of  this  complaint,  is  its  strong  ten- 
dency to  relapse ;  we  have  found  this  considerably  controlled  by 
the  proper  use  of  the  remedy  under  consideration.     Its  profuse 
and  unguarded  exhibition  aggravates  the  violence,  and  hastens 
the  progress  of  the  disease ;  we,  however,  give  it  only  with  a 
view  to  its  alterative  effect,  or  at  most,  till  the  mouth  is  slightly 
touched,  and  then  immediately  discontinue  it,  and  allow  the  sys- 
tem to  recover ;  when,  if  required,  it  may  be  again  given  in  the 
same  manner. 

1183.  The  blue  pill  in  doses  of  one  grain,  three  or  four  times  a 
day,  the  Plummer's  pills,  or  the  hydr.  cum  creta,  in  doses  of 
from  five  to  ten  grains,  two  or  three  times  a  day,  or  the  corro- 
sive sublimate,  as  before  directed,  are  the  best  forms  in  which  it 
can  be  administered.     As  auxiliaries,  and  to  allay  irritation,  the 
Dover's  powder,  the  decoction  of  sarsaparilla,  or  the  cicuta,  may 
be  often  used  with  advantage. 

Tonics. 

1184.  The  mineral  acids  have  been  recommended.    We  have 
never  tried  them  in  this  complaint,  but  from  the  beneficial  effects 
we  had  derived  from  them  in  some  analogous  diseases,  we  should 
expect  that  they  would  be  useful.  Mr.  Wardrop  prefers  the  sul- 
phuric; if  without  any  direct  experience  in  the  case,  we  might 
be  allowed  to  differ  from  so  high  an  authority,  we  would  say 
that  we  should  expect  more  from  the  nitric  or  nitro-muriatic 
acids. 

1185.  Mr.  Wardrop  highly  recommends  the  cinchona;  "it 
seems,"  he  says,  "  to  possess  as  specific  effect  in  this  disease  as 

45 


354  DISEASES    OF    THE    EYES. 

in  ague;"  we  have  not  seen  any  cases  in  which  it  appeared  ad- 
missible. It  is  well  known  that  intermittent  fever  sometimes 
attacks  the  eye;  we  have  seen  a  few  instances  of  it,  in  one 
case  it  appeared  in  the  form  of  sclerotitis,  accompanied  with 
considerable  redness  of  the  sclerotica,  a  febrile  paroxysm  every 
morning  at  ten  or  twelve  o'clock,  at  which  period  the  pain  was 
exceedingly  violent.  In  this  case  there  was  too  much  febrile 
excitement  constantly  present,  to  admit  of  the  use  of  bark,  but 
in  similar  cases,  attended  with  a  complete  intermission,  the  qui- 
nine would  no  doubt  be  useful. 

1186.  We  found  great  advantage  in  the  above  case,  and  in  some 
others  exhibiting  a  paroxysmal  type,  from  Fowler's  solution; 
it  may  be  given  in  the  usual  dose,  and  should  be  combined  with 
a  little  laudanum  and  compound  spirit  of  lavender;  in  this  form 
it  does  not  disagree  with  the  stomach. 

1187.  My  friend,  Dr.  Thomas  Harris,  of  the  United  States' 
navy,  informs  me  that  at  the  suggestion  of  Dr.  Physick,  he  used 
in  one  case,  the  tincture  of  guaiacum  with  decided  advantage, 
and   the  same  patient  has  on  several  subsequent  occasions  re- 
ceived prompt  relief  from  the  remedy;  he  however  prefers  the 
guaiacum  with  nitre  and  antimony,  which  he  has  often  used  with 
advantage. 

Local  Applications. 

1188.  We  have  derived  the  most  striking  benefits  in  this  dis- 
ease from  fomentations  of  a  decoction  of  poppy  heads  ;  they  are 
used  in  the  early  stages  of  the  disease  with  most  advantage,  al- 
leviating the  pain  in  the  eye  and  brow.  A  piece  of  flannel  should 
be  immersed  in  the  hot  decoction,  wrung  as  dry  as  possible,  and 
then  applied  over  the  eye  and  brow;  when  it  becomes  cool,  it 
should  be  again  immersed  in  the  decoction  and  reapplied. 

1189.  When  all  febrile  symptoms  are  subdued,  Mr.  Wardrop 
says  that  he  has  found  the  vinous  tincture  of  opium,  applied 
within  the  eyelids  twice  a  day,  decidedly  beneficial;  we  cannot 
speak  of  its  utility  from  our  own  experience. 

1190.  Blisters  applied  behind  the  ears,  or  to  the  back  of  the 
neck,  will  often  be  found  beneficial   in  the  latter  stages  of  the 
complaint;  when  applied  earlier,  while  considerable  febrile  ex- 
citement exists,  they  will  generally  aggravate  the  inflammation. 

1191.  Mr.  Wardrop  has  strongly  recommended*  the  evacua- 
tion  of  the  aqueous  humour,  particularly  in  those  cases  where 
proper  remedies  have  not  been  employed  at  an  earlier  period  of 
the  disease,  where  there  is  much  pain  in  the  brow  or  any  other 

*  Medico- Chirurgical  Transactions,  Vol.  X.p.  11. 


DISEASES    OF    THE    EYES.  355 

part  of  the  head,  where  the  cornea  has  become  dim  and  clouded, 
and  where  vision  is  impaired.  The  effects  of  the  operation  in 
these  cases,  is,  he  says,  instantaneous,  the  pain  in  the  head  is  re- 
moved and  seldom  returns,  and  the  transparency  of  the  cornea  is 
restored.  After  the  operation,  he  thinks  no  applications  neces- 
sary, except  fomentations  to  the  parts  around  the  eye.  We  are 
not  able  to  speak  from  experience  of  the  use  of  this  remedy,  and 
should  not  have  expected  any  permanent  or  perhaps  great  bene- 
fits from  it,  but  it  would  be  wrong  to  object  to  its  use  purely  on 
theoretical  grounds ;  if  it  produces  only  half  the  good  effects 
ascribed  to  it  by  Mr.  Wardrop,  it  is  a  valuable  remedy,  and  it 
comes  recommended  to  us  by  such  high  authority,  that  it  would 
be  justifiable  to  try  it. 

Regimen. 

1192.  The  remedies  noticed,  will  be  of  but  little  avail,  un- 
less the  patient  is  put  upon  a  properly  regulated  diet.    No  part 
of  the  treatment  requires  more  the  attention  of  the  physician 
than  this,  and  it  is  truly  surprising  how  little  it  is  generally  at- 
tended to,  the  patient  being  permitted  to  take  food  which  coun- 
teracts and  renders  abortive  every  thing  that  is  done  for  him. 

1193.  In  the  early  stages,  when  the  disease  is  attended  with 
much  pain  and  high  fever,  rigid  abstinence  must  be  enforced. 
Toast  and  water,  apple  water,  currant  jelly  and  water,  tamarind 
water,  lemonade  or  rice  water,  in  which  tartar  emetic  is  dissolved, 
should  be  the  only  nourishment  allowed — the  latter  we   have 
found  very  useful,  keeping  the  bowels  open,  especially  if  a  pur- 
gative has  been  premised,  and  also  acting  as  a  mild  diaphoretic, 
and  keeping  down  arterial  action.     Two  grains  of  tartar  emetic 
may  be  dissolved  in  a  quart  of  rice  water,  and  the  patient  allowed 
to  drink  of  it  freely. 

1194.  When  the  activity  of  the  pulse  has  been  reduced,  the 
patient  may  be  permitted  to  have  a  little  soft  boiled  rice,  sago, 
and  the  farinaceous  articles  of  food  generally,  in  moderate  quan- 
tities. 

1195.  As  the  disease  disappears,  the  quantity  of  these  articles 
should  be  increased  first,  and  then  the  patient  may  gradually 
return  to  the  use  of  animal   food,  beginning  with  weak   broths, 
and  avoiding  all  seasoning  except  a  little  salt;  as  long,  however, 
as  the  acute  stage  lasts,  animal  food,  in  any  shape,  is  inadmis- 
sible. ?••>»;; 

1196.  It  is  more  difficult  to  give  special  direction  for  regimen 
in  chronic  cases,  but  it  is  not  less  necessary  that  it  should  be  par- 
ticularly attended  to.     The  patient  must  avoid  all  stimulating 
substances,  and  confine   himself  to  light  and  easily  digestible 


356  DISEASES    OF    THE    EYES. 

food,  taken  in  small  quantities.  Physicians  generally  think  they 
have  done  enough,  when  they  restrict  their  patients  to  certain 
articles;  but,  when  bread  and  water  only  is  allowed,  injury  is 
often  produced  by  eating  too  much  of  the  former. 

1197.  Such  are  the  remedies  usually  employed  in  the  treat- 
ment of  inflammation  of  the  sclerotica.     It  is  impossible  to  give 
particular  directions  for  their  application  in  all  cases;  much  must 
be  trusted  to  the  judgment  of  the  practitioner,  and  that  tact  which 
an  attentive  observer  acquires  from  experience.    The  violence  of 
the  disease,  the  peculiar  constitution  of  the  individual,  and  many 
other  circumstances,  must  determine  the  extent  to  which  reme- 
dies should  be  employed,  and  decide  the  practitioner  in  the  choice 
of  them. 

1198.  It  may  be  stated  generally,  that  where  there  is  violent . 
pain   and   great  febrile  excitement,  they  should  be  reduced  by 
general  blood-letting,  saline  purgatives,  fomentations  to  the  eyes, 
small  doses  of  tartar  emetic,  the  saline  diaphoretics,  rigid  diet, 
&c.;  topical  depletion  is  then  to  be  employed,  blisters  behind  the 
ears,  sedatives,  diaphoretics,  &c.     After  the  acute  stage*  of  the 
disease  has  been  subdued,  or  where  it  is  attended  with  little  fe- 
brile excitement  at  the  commencement,  the  practitioner  should 
resort  to  mercury  in  some  form,  with  sedatives,  sarsaparilla,  &c.; 
where  it  puts  on  an  intermittent  form,  to  the  Fowler's  solution ; 
and  when  attended  with  gastric  disorder,  or  derangement  of  the 
biliary  apparatus,  to  mercurial  purgatives  or  antimonial  emetics. 

1199.  Treated  in  the  way  we  have  recommended,  the  disease 
under  consideration,  may,  in  almost  all  cases,  be  conducted  to  a 
fortunate  termination;   but  it  will  always  be  found  to  have  a 
strong  tendency  to  relapse,  and  this  must  be  guarded  against,  by 
avoiding  all  exposure  to  cold,  or  other  exciting  causes,  and  a 
strict  adherence  to  a  properly  regulated  diet. 

SECT.  III. — CORNEITIS. — INFLAMMATION  OP  THE  CORNEA. 

Anatomical  Structure,  and  Physiological  Characters.  - 

1200.  The  cornea  consists  of  three  distinct  tissues,  viz:-—  an 
external  covering  which  is  a  continuation  of  the  conjunctiva ;  its 
proper  substance;  and  an  internal  lining. membrane. 

1201.  The  conjunctiva!  coat  of  the  cornea  is  a  mucous  mem- 
brane, extremely  delicate,  transparent,  colourless,  devoid  of  epi- 
thelium, and,  in  a  healthy  state  at  least,  exhibits  no  villi  or  folli- 
cles.    It  is  abundantly  supplied  with  blood-vessels,  and  is  united 
to  the  subjacent  cornea  by  cellular  tissue,  which  is  too  short  to 
be  demonstrated.     From  no  villi  or  follicles  being  perceptible 


DISEASES    OP    THE    EYES.  357 

in  it,  and  its  acute  inflammation  usually  terminating  in  effusion 
of  lymph,  as  in  serous  tissues,  it  is  regarded  by  some  patholo- 
gists  as  belonging  to  this  class,  while  others  consider  it  a  sero- 
mucous  membrane.  It  certainly  is  more  closely  connected  with 
its  subjacent  tissue  than  any  other  of  its  class,  and  suffers  consi- 
derable modification  of  character;  but  we  are  inclined  to  consi- 
der it  still  as  essentially  a  mucous  membrane,  lymph  never  being 
poured  out  from  its  free  surface  as  in  serous  tissues,  but  always 
in  its  substance,  or  into  the  subjacent  cellular  tissue.* 

1202.  The  second  coat,  or  the  proper  substance  of  the  cornea 
is  a  transparent,  insensible,  elastic,  fibro-cartilaginous  tissue,  and 
consists  of  two  portions.  The  external  portion  is  composed  of  a 
number  of  concentric  or  parallel  laminae,  connected  by  a  cellular 
tissue,  the"  cells  of  which  are  filled  with  an  unctuous  fluid,  having 
all  the  characters  of  the  imperfectly  coagulated,  diaphanous  mu- 
cus, which  occurs  in  the  centre  of  the  inter-vertebral  fibro-caf- 
tilages.  This  cellular  tissue  is  abundantly  supplied  with  absorb- 
ents. By  boiling  the  cornea,  we  obtain  gelatine  similar  to  that 
obtained  from  the  other  fibre-cartilages.  M.  Gendrin,t  in  his 
admirable  work,  informs  us,  that  when  we  tear  the  cornea  after 
macerating  it  for  a  long  time  in  a  mineral  acid,  it  ruptures  pa- 
rallel to  its  circumference,  as  if  by  the  separation  of  concentric 
fibres ;  it  is,  however,  impossible  to  render  these  fibres  visible, 
but  M.  G.  thinks  that  the  above  experiments,  and  several  patho- 
logical considerations  prove  their  existence.  The  internal  portion 
is  very  dense,  and  is  united  to  the  other  by  cellular  tissue.  It 
is  very  important  to  bear  in  mind  these  two  divisions,  as  the 
pathological  phenomena  which  they  exhibit  are  somewhat  dif- 
ferent, and  in  consequence  of  the  greater  density  of  the  internal 
lamina,  it  is  much  more  difficult  to  penetrate  with  cutting  instru- 
ments than  the  exterior  ones,  and  in  operating  for  cataract  by  ex- 
traction, the  knife  is  apt  to  be  turned  by  the  former  portion,  and 
the  instrument,  instead  of  passing  through  the  anterior  chamber 
is  inserted  between  the  two  portions  of  the  cornea  we  have  de- 
scribed. The  blood-vessels  of  this  coat  are  derived  from  the 
sclerotica,  and  in  a  healthy  state,  like  the  vessels  of  the  other 
parts  of  the  cornea,  they  carry  a  colourless  fluid. 

1203.  The  third  tissue  is  an  extremely  delicate  serous  mem- 
brane, which  lines  the  internal  surface  of  the  cornea,  and  is  inti- 
mately attached  to  it.  The  existence  of  this  membrane  has  been 
denied  by  some  anatomists,  and  it  must  be  confessed  that  no  one 

*  At  least,  we  have  never  seen  filaments  of  lymph  formed  in  its  free  surface 
as  occurs  in  serous  membranes,  and  if  it  ever  happen,  it  cannot  be  of  more  fre- 
quent occurrence  than  in  other  mucous  membranes,  as  in  the  laryngeal  mu- 
cous membrane  in  croup,  &c. 

fHistoire  Anatomlque  des  Inflammations,  Vol.  I.  p.  331. 


358  DISEASES    OF    THE    EYES. 

has  succeeded  in  demonstrating  it  by  dissection,*  but  its  exist- 
ence is  rendered  highly  probable  from  analogy,  and  is  we  think, 
proved  by  several  pathological  phenomena  which  we  shall  indi- 
cate hereafter. 


§  I.  INFLAMMATION  OF  THE  Mucous  COVERING  MEMBRANE. 

1.  Jlcute  Inflammation. 

1204.  The  first  change  produced  in  the  mucous  membrane  of 
the  cornea  by  acute  inflammation,  is  a  slight  loss  of  transparency, 
arising  from  a  too  great  fulness  of  its  serous  vessels.    This  being 
the  effect  of  simple  congestion,  is  immediately  removed  on  the 
restoration  of   the  circulation.     If  the  irritation,  however,  be 
continued,  the  colourless  vessels  become  so  distended  as  to  admit 
red  blood,  and  they  can  then  be  readily  distinguished.     Around 
these  vessels  there  is  an  effusion  of  coagulable  lymph,  producing 
at  first  a  slight  cloudiness;  but  as  the  inflammation  advances 
more  lymph  is  poured  out,  the  conjunctiva  becomes  of  consider- 
able thickness,  opaque,  loses  its  smoothness  and  polish,  and  finally 
the  vessels  become  varicose,  transmit  red  blood,  the  lymph  is 
organized,  and  the  natural  appearance  of  the  conjunctiva  is  en- 
tirely destroyed. 

1205.  The  inflammation  may  be  arrested  at  various  periods  of 
its  progress,  the  absorbents  take  up  the  effused  lymph,  and  the 
transparency  of  the  conjunctiva  be  entirely  restored.     The  de- 
gree of  opacity  removed  by  these  vessels  is  often  surprising, 
especially  in  children.     We  have  seen  in  infants  in  whom  the 
whole  conjunctiva  of  the  cornea  was  thickened  and  opaque,  in 
consequence  of  puriform  inflammation  immediately  after  birth, 
the  lymph  entirely  absorbed,  and  the  transparency  of  the  cornea 
perfectly  restored. 

Treatment. 

1206.  The  indications  of  cure  are  first  to  arrest  the  inflamma- 
tion, and  then  to  promote  absorption.     The  first  is  to  be  accom- 
plished by  general  and  local  depletion,  revulsives,  and  diet.     In 
healthy  individuals,  general  depletion  is  to  be  preferred  to  local ; 
when  the  patient  will  not,  however,  bear  the  former,  or  after  it 
has  been  employed  to  sufficient  extent,  topical  depletion  may  be 
had  recourse  to,  and  for  this  purpose  we  usually  prefer  cups, 

*  Charles  Bell,  however,  says  in  his  Anatomy,  Vol.  III.  p.  249,  London, 
1803,  "after  maceration,  I  have  found  raised  in  the  fluid  a  very  delicate  arid 
transparent  membrane  from  the  internal  surface  of  the  cornea." 


DISEASES    OF    THE    EYES.  359 

which  may  be  applied  to  the  temples  or  behind  the  ears  and 
back  of  the  neck;  the  former  situation  is  usually  the  best:  or 
leeches  may  be  placed  behind  the  ears,  but  not  to  the  eyelids  as 
usually  recommended;  we  have  never  seen  them  applied  there 
in  the  early  stages  of  acute  inflammation  of  the  conjunctiva,  that 
they  did  not  aggravate  the  mischief. 

1207.  The  bowels  are  to  be  kept  open  by  saline  purgatives, 
and  the  most  rigid  diet  enjoined. 

1208.  After  the  violence  of  the  inflammation  has  been  sub- 
dued by  thelse   measures,  blisters  will  be   found  serviceable ; 
earlier  than  this,  however,  they  invariably  do  mischief.     They 
may  be  applied  behind  the  ears,  to  the  back  of  the  neck,  to  the 
temples,  or  to  the  arms  or  legs;  the  two  first  situations  are 
usually  to  be  preferred ;  after  the  inflammation  has  been  entirely 
subdued,  and  we  wish  to  institute  a  permanent  drain,  they  may 
be  applied  to  the  arms  or  the  legs,  especially  the  former,  with 
advantage.     A  seton  will  answer  this  last  purpose  exceedingly 
well.     As  revulsives  in  the  earlier  stages,  pediluvia  will  be  found 
useful. 

1209.  When  the  inflammation  is  dissipated,  stimulants  must 
be  applied  to  the  cornea  to  promote  the  absorption  of  the  effused 
lymph  ;  for  this  purpose  an  immense  number  of  remedies  have 
been  recommended ;  the  best  are  the  nitrate  of  silver,  the  red 
precipitate  ointment,  the  corrosive  sublimate,  and  sulphate  of 
copper.     I  prefer  of  these  the  nitrate  of  silver,  which  should  be 
employed  in  solution,  one  to  four  grains  to  the  ounce  of  distilled 
water,  dropped  into  the  eye  several  times  a  day.     This  solution 
soon  decomposes  unless  kept  from  the  air  and  light;  as  soon, 
therefore,  as  it  assumes  a  reddish  colour,  and  small  particles  are 
seen  floating  in  it  when  shaken,  fresh  should  be  prepared.     The 
corrosive  sublimate  is  used  in  solution,  one  or  two  grains  to  the 
ounce  of  distilled  water.     Much  difficulty  is  often  experienced 
in  applying  these  solutions  to  the  eye;  it  may  be  accomplished 
with  great  ease  by  means  of  a  small  quill  or  glass  tube  about  two 
inches  long,  which  should  be  introduced  halfway  into  the  solu- 
tion, and  the  upper  orifice  then  closed  with  a  finger;  the  eyelids 
are  to  be  separated,  and  the  lower  end  of  the  quill  or  tube  placed 
near  the  cornea ;  the  finger  being  now  removed  from  the  orifice, 
the  fluid  will  flow  out.   Great  care  should  be  taken  not  to  employ 
these  remedies  too  early,  that  too  much  action  be  not  excited  by 
them,  and  that  it  be  only  temporary;  otherwise,  instead  of  ab- 
sorption being  promoted,  there  will  be  an  increased  deposition 
of  lymph. 

1210.  Dupuytren,  we  learn,  is  extremely  successful  in  the 
treatment  of  opacities  of  the  cornea.     He  removes  the  inflamma- 
tion by  the  usual  remedies,  and  then  orders  to  be  blown  into  the 


360  DISEASES    OF    THE    EYES. 

eye  equal  parts  of  prepared  tutty,  sugar  candy,  and  calomel  mix- 
ed together  and  reduced  to  an  impalpable  powder.  This  he  con- 
tinues for  several  weeks,  and  it  is  said  he  seldom  fails  to  effect 
a  cure.  If  the  opacity  is  very  old  and  large,  he  introduces  a  seton 
into  the  back  of  the  neck,  and  the  powder  is  blown  into  the  eye 
some  minutes  at  a  time. 

1211.  In  several  cases  of  extensive  opacities  of  the  corneal 
conjunctiva,  of  long  standing,  we  have  employed  with  great  ad- 
vantage finely  powdered  loaf-sugar  and  calomel,  applied  to  the 
spot  with  a  camel's  hair  brush. 

1212.  Local  stimulants  will  not,  however,  always  succeed  in 
effecting  absorption;  when  this  is  the  case,  mercury  should  be 
resorted  to,  but  not  to  the  extent  of  producing  salivation.     We 
usually  prefer  the  calomel  in  combination  with  tartrite  of  anti- 
mony and  nitre;  the  proportion  of  nitre  should  be  larger  than  in 
the  common  nitrous  powders.     Few  cases,  except  in  very  de- 
praved constitutions,  will  resist  the  judicious  employment  of  this 
combination,  with  a  solution  of  nitrate  of  silver,  to  the  eye,  or 
the  calomel  and  loaf-sugar,  together  with  a  drain  established  by 
a  seton  in  the  neck,  or  a  perpetual  blister  to  the  arms.  It  is,  how- 
ever, often  necessary  to  continue  these  remedies  for  a  considera- 
ble time. 

> 

2.   Chronic  Inflammation. 

1213.  In  chronic  inflammation  the  blood-vessels  soon  become 
varicose,  convey  red  blood,  and  anastomose.     The  effusion  of 
lymph  is  usually  more  general  than  in  acute  inflammation,  fre- 
quently producing  a  general  opacity  and  thickening  of  the  con- 
junctiva; this  membrane  seems  to  lose  its  close  attachment  to  its 
subjacent  tissue,  and  the  cornea  frequently  "  resembles  in  ap- 
pearance the  green  colour  which  is  presented  by  the  fracture  of 
common  gun-flint;  sufficiently  diaphanous  to  admit  the  percep- 
tion of  light,  yet  too  opaque  to  render  external  objects  visible  to 
the  patient,  excepting  by  their  shadows,  rendering  it  impossible 
to  ascertain  the  colour  of  the  iris,  or  distinguish  the  limits  of  the 
pupil."* 

Treatment. 

1214.  In  the  treatment  of  this  inflammation,  general  blood- 
letting will  be  found  of  little  service ;  topical  depletion  is  much 
more  useful.     The  solution  of  nitrate  of  silver  should  early  be 
resorted  to,  and  afterwards  the  solution  of  corrosive  sublimate 

*  Vetch.  A  Practical  Treatise  on  the  Diseases  of  the  Eye,  p.  68. 


DISEASES    OF    THE    EYES.  361 

or  the  red  precipitate  ointment  may  be  substituted,  if  the  first 
does  not  succeed  in  effecting  a  cure.  Blisters  are  useful,  and  in 
some  cases  we  have  seen  them  applied  with  advantage  over  the 
eyelids.  The  varicose  vessels  should  be  divided  with  a  knife, 
or  elevated  with  a  small  hook  and  a  portion  cut  out  with  scissors. 

1215.  This  inflammation  is  often  excited  and   kept  up  by  a 
granular  state  of  the  eyelids,  in  others  by  the  eversion  of  the 
lids,  in  such  cases  we  need  not  expect  a  cure  until  the  cause  pro- 
ducing it  is  removed. 

1216.  Preternatural  Growths  produced  by    Chronic  In- 
flammation.— Circumscribed  tumours,  of  a  dense  and  firm  tex- 
ture, are  sometimes  formed  upon  the  conjunctiva  of  the  cornea, 
and  attain  a  considerable  magnitude,  but  such  cases  are  rare. 
Mr.  Travers  says  that  he  has  "  excised  the  anterior  hemisphere 
of  the  eyeball  in  an  elderly  lady,  in  whom  the  cornea  was  con- 
cealed by  a  tumour  of  a  dark  purple  colour,  protruding  to  such 
an  extent  between  the  eyelids,  as  to  occasion  great  inconvenience 
and  deformity.   It  had  the  appearance  of  being  disposed  in  lobes, 
somewhat  resembling  a  bunch  of  currants  of  unequal  size.     On 
dissection,  the  cornea  and  sclerotica  proved  to  be  entire,  and  the 
morbid  growth  lying  upon  and   adhering  to  the  corneal,  and  a 
small  portion  of  the  sclerotic  surface,  had  acquired  the  tabulated 
appearance,  as  if  by  degeneration  of  the  covering  conjunctiva; 
for  delicate  white  bands,  the  only  vestiges  of  this  membrane, 
were  seen  intersecting  the  lobules  at  irregular  distances,  in  the 
form  of  sceptae.     The  substance,  on  section,  was  firm,  of  a  dark 
colour,  here  and  there  mottled  with  white,  and  measured  a  quar- 
ter of  an  inch  in  thickness,  from  the  external  surface  of  the  cor- 
nea."* 

3.    Vesicular  Inflammation. 

1217.  In  certain  cases  of  mild  inflammation,  the  serous  vessels 
pour  out  a  fluid  either  in  the  substance  of  the  conjunctiva,  or  in 
its  subjacent  cellular  tissue.  This  secretion  is  very  circumscribed, 
and  forms  small  diaphanous  vesicles,  which  usually  burst,  dis- 
charge their  contents,  and  leave  an  ulcer,  t    This  may  extend  to 
the  proper  coat  of  the  cornea,  or  the  breach  may  be  repaired. 
This  reparation  may  be  effected  by  the  lymphatic  vessels,  and 
without  any  red  vessels  being  visible ;  most  frequently,  however, 
blood-vessels  may  be  seen  running  to  the  ulcer ;  these  deposit  a 
yellowish  lymph,  which  is  sometimes  removed  by  the  absor- 
bents, at  others  remains,  forming  an  opaque  cicatrix. 

*  Synopsis  of  the  Diseases  of  the  Eye,  p.  102,  ed.  3d.  London,  1824. 
•}•  This  affection  has  been  described  by  Gendrin.  Op.  cit.  Vol.  I.  p.  523. 

46 


362  DISEASES    OF    THE    EYES. 


Treatment. 

1218.  Tliis  inflammation  is  to  be  treated  by  topical  depletion, 
revulsives,  and  astringent  washes,  the  best  of  which  are  the  ni- 
trate of  silver  and  sulphate  of  copper. 

4.  Pustular  Inflammation. 

1219.  Pustules  are  not  unfrequently  formed  in  the  conjunctiva 
of  the  cornea,  and  as  in  other  mucous  membranes,  they  are  the 
result  of  inflammation  of  mucous  follicles,  we  are  inclined  to 
consider  them  here  as  the  consequence  of  follicular  inflamma- 
tion, though  follicles  have  not  been  as  yet  demonstrated  in  this 
part.      It  may  be  supposed  by  some  that  these  pustules  are  mere 
abscesses;  we  cannot,  however,  consider  them  as  such,  since 
they  do  not  exhibit  the  common  appearances,  nor  follow  the 
usual  course  of  abscesses,  and  they  often  occur  as  concomitants 
of  unquestionably  follicular  inflammations,  as  small-pox,  aphthae, 
&c.     These  pustules  are  usually  situated  near  the  margin  of  the 
cornea.     At  the  very  commencement  of  this  inflammation,  mi- 
nute fasciculi  of  vessels  presenting  a  triangular  form,  may  be 
perceived  running  upon  the  cornea,  and  at  the  point  of  each 
plexus  a  pustule  forms.     At  first,  this  pustule  generally  appears 
like  a  dusky,  yellow,  or  reddish  spot,  a  little  elevated  above  the 
surface  of  the  cornea,  and  in  a  short  time  it  becomes  a  conical 
tumour.     Coagulable  lymph  is  secreted  around  the  fasciculi  of 
vessels,  and  the  cornea  in  the  vicinity  of  the  pustule  becomes 
more  or  less  dense.     The  vessels  always  run  in  fasciculi,  point- 
ing towards  the  pustule,  and  the  redness  is  never  diffused,  as  in 
common,  acute,  or  chronic  inflammation.  This  disease  is  attend- 
ed from  the  commencement  with  pain,  usually  very  acute,  and 
lachrymation ;  these  subside  as  the  disease  advances.     If  the  in- 
flammation be  not  now  arrested,  a  straw-coloured  purulent  fluid 
is  secreted  in  the  pustule;  its  apex  ulcerates;  it  discharges  its 
contents,  and  an  ulcer  is  left,  the  edges  of  which  are  opaque. 
The  ulceration  may  extend  to  the  cornea,  or  restoration   take 
place;  this  latter  is  effected  by  the  effusion  of  coagulable  lymph, 
which  becomes  organized,  and  the  excess  is  either  absorbed,  or 
an  opaque  cicatrix  is  left. 

1220.  The  inflammation  in  this  disease  is  very  apt  to  return 
on  any  slight  irritation.  In  some  cases  where  it  returns  fre- 
quently, the  pustule  seldom  ulcerates,  but  disappears  gradually, 
after  having  remained  a  few  days. 

1221*  This  disease  sometimes  occurs  simultaneously  with, 
and  appears  to  be  connected  with  small-pox,  aphthae,  and  similar 


DISEASES    OP    THE    EYES.  363 

affections;  at  others,  it  appears  to  be  produced  by  some  circum- 
scribed local  irritation,  or  to  be  dependent  upon  a  peculiar  dia- 
thesis or  state  of  the  constitution.  It  usually  occurs  in  children, 
and  sometimes  spreads  through  schools  and  large  families;  it  is 
met  with,  however,  in  persons  of  all  ages.  These  pustules  bear 
some  analogy  to  the  aphthae  observed  in  the  cavity  of  the  mouth, 
on  the  tongue,  lips,  and  on  the  internal  surface  of  the  intestinal 
canal ;  and  Professor  Himly  says,  that  at  a  time  when  aphthae  of 
the  throat  were  very  frequent  at  Brunswick,  he  also  found  many 
small  vesicles  beginning  with  an  inflammation  of  the  sclerotic 
coat;  and  also  sometimes,  but  more  rarely  of  the  cornea.  Once 
he  saw  a  whole  family  affected  with  this  disease,  one  after  an- 
other. "  It  was,"  he  observes,  "  a  true  catarrhal  affection,  and  in 
some  cases  these  vesicles  disappear  by  diaphoretic  medicines,  in 
some  by  blisters,  camphor,  and  antimony,  without  any  local  ap- 
plication, except  mucilaginous  ones.  I  think  that  it  is  just  the 
same  disease  as  aphthae  of  the  intestinal  canal,  of  the  cornea,  of 
the  glans  penis,  and  other  fine  continuations  of  the  external  skin. 
Those  on  the  cornea  become  worse  if  they  are  opened,  and  if 
they  open  themselves  and  form  ulcers,  they  generally  dry  up  by 
means  of  borax  and  white  vitriol,  but  if  they  are  neglected,  they 
cause  sometimes  considerable  ulcers  which  are  very  obstinate 
and  hurtful  to  the  cornea."* 

Treatment. 

1222.  In  the  treatment  of  this  inflammation,  general  blood- 
letting is  not  often  demanded  ;  topical  depletion,  however,  is 
almost  always  useful,  and  this  may  be  effected  either  by  cups  or 
leeches.  The  bowels  should  be  kept  open,  and  for  this  purpose 
we  prefer  in  the  first  instance  calomel,  and  then  a  mixture  of 
pulv.  rhei  and  creta  ppt.  Blisters  are  also  useful,  and  they  should 
be  applied  to  the  back  of  the  neck,  behind  the  ears,  or  to  the 
arm,  and  kept  open.  If  the  pain  be  very  violent,  fomentations 
will  sometimes  afford  considerable  relief.  After  the  inflamma- 
tion is  reduced  by  these  measures,  the  astringent  collyria  should 
be  employed  ;  the  best  is  the  solution  of  nitrate  of  silver.  In  the 
very  onset  of  the  disease  it  is  also  useful,  and  should  the  patient 
be  seen  early  enough,  by  touching  the  plexus  of  vessels  with  the 

*  We  have  made  this  quotation,  for  which  we  are  indebted  to  Wardrop's 
valuable  essays  on  the  morbid  anatomy  of  the  human  eye,  never  having  seen 
the  original,  with  some  hesitation,  as  the  disease  is  termed  vesicular.  Whether 
the  affection  consisted  of  true  pustules,  or  really  vesicles,  or  whether  an  error 
has  been  committed  by  the  author  or  the  translator,  we  are  unable  to  deter- 
mine: but  as  the  swellings  are  said  to  resemble  aphthae,  which  are  true  pus- 
tules, i.  e.  inflammations  of  cryptx,  we  are  inclined  to  believe  that  there  is  a 
mistake  somewhere,  and  that  the  disease  consisted  of  pustules. 


364  DISEASES    OF    THE    EYES. 

argent,  nit.  and  administering  at  the  same  time  a  smart  purga- 
tive, the  disease  may  occasionally  be  arrested.  In  the  latter 
stages  of  this  disease  the  vinum  opii  has  been  strongly  recom- 
mended. We  cannot  say  any  thing  respecting  its  value  from 
our  own  observation,  as  we  have  little  experience  with  the  re- 
medy in  ophthalmic  inflammation.  In  a  few  instances  in  which 
we  employed  it,  we  derived  little  or  no  advantage  from  it,  and 
therefore  have  not  persevered  in  its  use,  but  it  has  been  so  highly 
extolled  by  respectable  writers,  that  its  utility  in  some  cases  can 
scarcely  be  doubted.  When  the  pustule  is  evidently  filled  with 
pus,  and  there  is  no  prospect  of  its  being  absorbed,  it  is  better  to 
open  it  at  once  carefully  with  a  sharp  cataract  needle.  The  ulcer 
that  is  left  may  be  cured,  and  the  absorption  of  the  lymph  pro- 
moted by  the  judicious  use  of  the  nitrate  of  silver  and  revulsives. 

5.    Ulcerative  Inflammation. 

1223.  The  conjunctiva  bears  the  same  relation  to  the  cornea 
that  the  synovial  membrane  does  to  cartilage,  and  periosteum  to 
bone,  and  like  these  membranes,  it  is  much  less  disposed  to  ul- 
cerate than  the  part  it  covers.      Ulcers,  however,  do  form  in  it, 
and  they  are  described  by  M.  Gendrin,*  as  commencing  always 
by  the  formation  of  a  very  small  tubercle,  at  first  red,  very  little 
prominent,  and  soon  of  a  cindry  white.     This  small  tubercle, 
which  is  produced  by  inflammatory  effusion  into  the  conjunctiva, 
has  been  often  mistaken  for  abscess  beneath  or  in  the  thickness 
of  the  conjunctiva.    As  soon  as  the  ulceration  has  destroyed  this 
tumour,  we  see  a  solution  of  continuity  having  elevated  edges, 
livid  red,  irregular,  and  at  the  base  gray  and  cindry.   It  remains 
in  this  state  during  the  existence  of  the  inflammation,  but  when 
cicatrization  is  about  commencing,  the  edges  of  the  ulcer  become 
less  prominent,  the  redness  less  livid,  the  base  of  the  ulcer  as- 
sumes a  reddish  appearance,  the  size  of  the  ulcer  diminishes,  and 
if  it  has  not  extended  beyond  the  thickness  of  the  cornea,  it  ap- 
pears like  a  slight  excoriation.     This  may  be  the  usual  appear- 
ance and  progress  of  ulcers  of  the  cornea,  but  they  certainly  do 
not  always  commence  in  this  manner.   They  often  succeed  vesi- 
cular and  pustular  inflammation ;  and  we  have  seen  them  appa- 
rently produced  by  a  real  ulcerative  absorption,  the  cornea  ex- 
hibiting no  apparent  loss  of  transparency,  and  no  coloured  ves- 
sels or  lymph  being  visible. 

1224.  ElizaDavis,  aetat.  thirty,  servant,  applied  at  the  Pennsyl- 
vania Eye  Infirmary,  January  30th,  1824.      She  had  slight  in- 
flammation of  the  conjunctiva  of  one  eye,  and  an  indistinctness 

*  Op.  Cit.  Vol.  I.  p.  683. 


DISEASES    OF    THE    EYES.  365 

of  vision,  for  which  there  was  no  visible  cause.  By  the  loss  of  a 
little  blood,  purging,  and  low  diet,  the  inflammation  abated  in  a 
few  days,  but  the  indistinctness  of  vision  increased.  At  this 
period  the  cornea,  though  transparent,  did  not  present  a  perfectly 
natural  appearance,  and  on  carefully  examining  it  in  certain  po- 
sitions, a  very  minute,  irregular  depression  was  perceived  by  the 
irregular  reflexion  of  the  light.  On  examination  with  a  micro- 
scope, at  least  fifty  ulcers  were  seen  on  the  cornea,  all  so  minute 
that  they  could  not  be  perceived  by  the  naked  eye ;  the  one  at 
first  seen  was  evidently  formed  by  the  union  of  three  or  four. 
These  ulcers  remained  for  several  weeks,  but  ultimately  entirely 
healed.  At  no  period  was  there  any  effused  lymph  or  red  ves- 
sels to  be  seen  on  the  corneal  conjunctiva. 

1225.  Mr.  Ryall  is,  we  believe,  the  only  writer  who  has  no- 
ticed these  minute  ulcers.* 

Treatment. 

1226.  The  first  object  to  be  attained  in  the  treatment  is  the  re- 
duction of  the  inflammation,  and  next  to  promote  cicatrization. 
The  first  is  to  be  accomplished  by  the  usual  antiphlogistic  mea- 
sures, and  for  the  second,  the  best  remedy  is  the  solution  of  ni- 
trate of  silver.     Mr.  Ryall  sayst  that  he  has  "  not  unfrequently 
known  patients  of  weakly,  strumous  habits  to  have  been  con- 
demned to  long  confinement  in  darkened  apartments,  to  a  strict 
antiphlogistic  regimen,  and  even  to  the  influence  of  mercury, 
whose  miseries  might  have  been  in  a  great  measure  curtailed, 
had  the  precise  nature  of  their  complaint  been  timely  discovered, 
and  the  nitrate  of  silver  applied. "    These  measures  will  usually 
effect  a  cure ;  should  they  fail,  and  the  ulceration  involve  the 
proper  lamina  of  the  cornea,  we  shall  point  out  the  treatment 
when  we  come  to  consider  the  ulcerative  inflammation  of  this 
part. 

§  II.  INFLAMMATION  OF  THE  PROPER  TISSUE  OF  THE  CORNEA. 

1.  Acute  Inflammation. 

1227.  The  first  step  of  acute  inflammation  is  evinced  by  en- 
gorgement of  the  vessels  of  the  part,  and  in  the  cornea  it  be- 
comes visible  by  a  slight  haziness  or  loss  of  transparency.     At 
this  stage  resolution  may  take  place  by  the  contraction  of  the 

*  Transactions  of  the  Association  of  Fellows  and  Licentiates  of  the  King  and 
Queen's  College  of  Physicians  in  Ireland,  Vol.  V.  p.  2. 
fOp.  Cit.  p.  3. 


366  DISEASES    OF    THE    EYES. 

lymphatic  vessels  to  their  original  diameters;  but  if  the  disease 
advances,  the  vessels  become  distended,  and  first  admit  a  dense 
coagulable  lymph,  next  the  red  globules  of  the  blood,  and  deep- 
seated  vessels  may  then  be  seen  in  the  substances  of  the  cornea, 
always  running  from  the  circumference  towards  the  centre  of 
the  part.  These  vessels  are  usually  most  visible  at  the  junction, 
of  the  sclerotic  coat  with  the  cornea,  and  on  close  observation 
they  may  be  seen  forming  at  this  part  a  beautiful  red  zone  of  rec- 
tilineal vessels,  which  zone  is  very  different  from  that  occurring 
in  iritis;  the  latter  being  formed  by  anastomosing  vessels,  and 
situated  a  short  distance  from  the  cornea,  leaving  a  whitish  zone 
within  it.  The  inflammation  may  terminate  in  effusion  of  coagu- 
lable lymph,  or  a  puriform  lymph,  usually  succeeded  by  ulcera- 
tion,  or  the  action  may  be  so  violent  as  to  produce  gangrene  or 
sloughing ;  in  some  few  cases  blood  has  been  effused  between 
the  laminae  of  the  cornea.  The  lymph  is  generally  deposited  in 
the  cellular  tissue  connecting  the  laminae;  and  the  extent  of  this 
effusion  varies,  sometimes  being  confined  to  a  small  space,  at 
others  occupying  the  whole  of  the  cornea.  If  the  inflammation 
has  not  been  very  violent,  or  is  early  arrested,  the  lymph  may 
be  removed  by  the  absorbents,  and  the  transparency  of  the  cor- 
nea in  great  part,  or  even  entirely  restored;  sometimes,  however, 
the  lymph  becomes  organized,  and  red  vessels  may  be  seen  rami- 
fying through  it.  If  the  inflammation  is  severe,  and  continues  for 
any  length  of  time,  considerable  disorganization  is  produced,  the 
cornea  swells,  its  vessels  become  varicose,  and  transmit  red  blood; 
its  laminae  are  separated,  coagulable  lymph  is  effused  in  their 
substance  and  between  their  lamina?,  and  the  whole  cornea  be- 
comes thickened,  opaque,  and  spongy.  The  pain  that  attends 
this  disease  is  very  various,  and  seems  to  depend  upon  the  ex- 
tent to  which  the  sclerotica  and  the  internal  tissues  are  in- 
volved. 

1228.  Inflammation  of  the  cornea  may  be  produced  by  exten- 
sion from  the  sclerotica  or  conjunctiva,  and  by  the  usual  causes 
of  inflammation  elsewhere.     Persons  with  a  scrofulous  consti- 
tution are  peculiarly  liable  to  it,  and  in  them,  it  is  very  diffi- 
cult of  cure,  the  disease  often  assuming  a  chronic  character,  and 
relapses  taking  place  on  the  slightest  exposure  to  the  exciting 
causes. 

Treatment. 

1229.  In  the  management  of  acute  inflammation  of  the  cornea, 
the  importance  of  the  organ  affected,  and  the  rapidity  with  which 
disorganization  may  take  place,  must  be  kept  constantly  in  mind. 
The  treatment  must  of  course  be  regulated  by  the  violence  of  the 


DISEASES    OP    THE    EYES.  367 

inflammation  and  the  habit  of  the  patient,  but  prompt  and  effi- 
cient measures  should  always  be  adopted.  In  the  commence- 
ment, general  blood-letting  is  almost  always  demanded,  and  for 
this  purpose  opening  the  temporal  artery  has  been  highly  re- 
commended by  some  writers.  We  are  not  aware  of  any  advan- 
tages that  it  possesses  over  venesection,  and  a  bandage  around 
the  head  being  usually  necessary  to  arrest  the  flow  .of  blood,  the 
circulation  of  the  head  is  impeded,  and  its  vessels  become  en- 
gorged ;  and  even  if  no  bandage  be  required,  the  wound  gene- 
rally proves  a  very  injurious  source  of  irritation;  venesection 
should  therefore  always  be  preferred  where  it  can  be  accom- 
plished. After  general  depletion  has  been  carried  as  far  as  the 
violence  of  the  disease  may  demand,  or  the  constitution  of  the 
patient  justify,  topical  depletion  will  generally  be  required.  It 
is  impossible  to  lay  down  any  very  accurate  rules  by  which  it 
may  be  known,  at  what  period,  and  under  what  circumstances, 
topical  is  to  be  substituted  for  general  depletion.  In  inflamma- 
tion of  organs  not  essential  to  life,  occurring  in  healthy  indivi- 
duals, and  where  none  of  the  vital  organs  are  implicated,  general 
depletion  may  be  pushed  to  a  greater  extent  than  is  usually  sup- 
posed, and  with  much  advantage;  and  the  usual  error  we  suspect 
is  in  not  depleting  sufficiently.  But  in  diseases  of  vital  organs, 
or  where  these  have  become  deeply  implicated,  and  where  the 
inflammation  has  been  of  long  continuance,  and  become  esta- 
blished, and  especially  in  broken  down  or  depraved  constitu- 
tions— topical  must  be  early  substituted  for  general  depletion,  and 
often  entirely  depended  on ;  as  the  latter,  in  these  cases,  debili- 
tate the  healthy  organs  more  than  it  relieves  the  affected  ones, 
and  the  restorative  powers  are  thus  weakened  or  destroyed. 
When  a  good  deal  of  pain  attends  the  disease,  much  relief  is 
often  afforded  by  fomentations,  especially  by  means  of  flannel 
wrung  out  of  a  hot  decoction  of  poppy-heads;  but  these  applica- 
tions should  'not  be  too  long  continued,  and  warm  poultices 
should  be  invariably  avoided  as  eminently  injurious,  promoting 
suppuration  and  disorganization  of  the  cornea. 

1230.  Purgatives  and  revulsives  will  be  found  highly  useful  ^ 
their  employment  must  be  regulated   by  the  rules  laid  down 
in  inflammation  of  the  conjunctiva.     (See  pp.  335  and  336.)     A 
proper  diet  must  also  be  enjoined.     (See  p.  355.) 

1231.  The  inflammation  being  reduced  by  the  above  measures, 
if  opacity  remain   from   the  effusion   of  lymph,  its  absorption 
must  be  promoted  by  keeping  down  the  inflammatory  action  by 
occasional  local   depletion,  by  low  diet,  by  stimulating  applica- 
tions, such  as  the  solutions  of  nitrate  of  silver  and  corrosive  sub- 
limate, red   precipitate  ointment,  &c.     When  other  means  fail, 


368  DISEASES    OF    THE    EYES. 

mercury  urged  to  salivation  in  combination  with  the  above  mea- 
sures, will  sometimes  succeed ;  but  we  prefer  the  combination 
already  noticed  of  calomel,  nitre,  and  tartar  emetic,  and  think 
we  have  derived  most  advantage  from  its  alterative  action  than 
when  urged  to  salivation.  In  scrofulous  persons  salivation  is 
much  to  be  deprecated  ;  we  have  seen  such  kept  under  the  long- 
continued  influence  of  mercury  for  opacities  of  the  cornea,  to  the 
great  injury  of  their  constitutions  and  the  evident  aggravation  of 
the  disease,  relapses  of  inflammation  occurring  on  every  variation 
of  temperature,  from  the  increased  susceptibilities  thus  created, 
and  the  vessels  of  the  cornea  becoming,  from  the  frequent  attacks 
of  disease,  permanently  enlarged.  In  such  cases  the  alterative 
effect  attained  by  the  use  of  the  combination  just  noticed,  will 
often  be  found  useful,  but  should  be  administered  with  caution, 
and  frequently  intermitted  for  fear  of  salivation,  and  during  these 
intervals  the  bowels  should  be  kept  free  by  the  daily  adminis- 
tration of  rhubarb  and  prepared  chalk. 

1232.  When  the  varicose  vessels  belong  to  the  conjunctiva,  it 
has  been  recommended  to  take  up  a  fold  of  this  membrane,  and 
excise  a  small  portion  so  as  to  divide  them,  or  when  they  are 
somewhat  deeper  to  divide  them  with  a  knife,  but  our  own  ex- 
perience would  not  lead  us  to  say  much  in  favour  of  this  prac- 
tice. 

1233.  By  the  judicious  employment  of  the  means  indicated, 
very  extensive  opacities  of  the  cornea  may  be  removed  ;  indeed, 
unless  the  lymph  has  become  organized,  great  benefit,  or  even  a 
cure  is    mostly   effected,    especially    in    young   patients;  even 
where  the  lymph  has  became  in  a  degree  organized,  and  varicose 
vessels  are  seen  running  to  the  part,  something  is  often  gained. 
When  both  corneae  are  affected,  and  only  a  small  portion  trans- 
parent, if  this  be  not  over  the  natural  pupil,  an  artificial  one  may 
be  made  opposite  the  transparent  spot,  and  a  useful  degree  of 
vision  restored. 

2.    Chronic  Inflammation. 

1234.  This  produces  a  slow  change  in  the  texture  of  the  cornea, 
rendering  it  opaque,  indurated,  condensed,  and  more  easily  torn 
than  in  health.   Such  disorganization  is  not  produced  in  the  cor- 
nea, without  the  inflammation  extending  to  the  conjunctiva,  and 
often  to  the  sclerotica;  lymph  is  deposited  in  both  these  tunics, 
especially  the  former,  which    loses    its    transparency,  and  the 
blue  colour  of  the  latter  is  destroyed.     The  globe  of  the  eye 
appears  as  if  covered  with  a  fibrous  fascia,  the  fibres  of  which 
converge  towards  the  centre  of  the  cornea,  and  presents  a  yel- 


369 

low,  pearly  appearance,  not  unaptly  compared  to  that  of  the  in- 
side of  an  oyster  shell,  over  which  varicose  vessels  sometimes 
ramify. 

1235.  These  cases  are  usually  beyond  the  resources  of  art,  the 
effusion  of  lymph  having  usually  been  so  profuse  as  to  aggluti- 
nate the  cells  of  the  intei'lamellar  tissue,  and  the  absorbents  are 
no  longer  capable  of  effecting  its  removal. 

1236.  A  deposit  of  lymph,  formed  perhaps  by  a  slow,  chronic 
inflammation,  is  often  seen  in  old  men  ;  the  lymph  is  deposited 
in  a  regular  circle  around  the  cornea,  forming  what  has  been  de- 
nominated the  arcus  senilis.     Mr.  Wardrop*  says  that  he  ha& 
seen  it  at  all  periods  of  life,  even  in  very  young  subjects. 

3.  Suppurative  Inflammation. 

1237.  Inflammation  of  the  cornea  rarely,  if  ever,  terminates 
by  the  effusion  of  true  pus;  but  instead  of  this  fluid,  a  tenacious, 
yellowish  substance,  partaking  more  of  the  nature  and  properties- 
of  lymph,  is  secreted  in  the  cellular  tissue  connecting  the  laminae 
of  the  cornea.     This  termination  is  like  abscess  in  common  cellu- 
lar tissue.     When  the  deposit  is  small,  it  is  frequently  removed 
by  the  absorbents,  and  often  without  any  vestige  being  left. 
Sometimes  coagulable  lymph  is  effused  around  the  deposit,  or  in 
its  place,  and  a  permanent  cloudiness  is  left.     When  the  deposit 
of  pus  is  large,  the  superficial  laminae  are  usually  removed  by 
absorption,  the  contents  of  the  abscess  are  thrown  off  in  the  same 
manner  as  sloughs,  and  an  ulcer  is  left.     This  may  heal  by  the 
usual  process,  and  the  transparency  of  the  cornea  be  restored, 
even  when  a  considerable  portion  of  it  has  been  affected.     Mr. 
Vetcht  says  that  he  has  seen  the  cornea  not  only  recover  its 
transparency  after  two-thirds  of  its  extent  had  been  destroyed 
in  this  way,  but  that  he  has  frequently  procured  a  transparent 
cicatrization  after  the  second,  and  even  third  attack  of  inflamma- 
tion, followed  by  ulcer  and  slough. 

Treatment. 

1238.  The  treatment  must  be  commenced  by  reducing  the  in- 
flammation, which  is  to  be  accomplished  by  the  measures  already 
noticed ;  principally  topical  depletion  and  purgatives,  and  blis- 
ters ;  the  latter  should  early  be  resorted  to ;  by  these  means  the 
effusion  will  generally  be  absorbed.     When  the  abscess  is  very 
superficial,  and  the  external  laminae  are  bulged  out,  it  is  well  to 
open  it  with  a  cataract  needle,  and  evacuate  its  contents  by  en- 

*  Op.  cit.  vol.  i.  f  Op.  cit. 

47 


370  DISEASES   OF    THE    EYES. 

tangling  them  with  the  point  of  the  needle,  and  drawing  them 
out.  In  abscess  deeply  seated,  no  advantage  is  obtained  from  this 
practice.  When  the  effusion  is  very  large,  and  there  is  a  dispo- 
sition to  slough,  as  usually  occurs  in  depraved  constitutions,  the 
system  must  be  supported  by  tonics,  such  as  the  nitric  acid,  bark, 
&c.  and  a  nourishing  diet. 

4.   Ulcerative  Inflammation. 

1239.  The  cornea,  like  the  other  fibro- cartilages,  very  fre- 
quently ulcerates.     The  conjunctiva  bears  the  same  relation  to 
the  cornea,  as  we  have  already  observed,  that  periosteum  does  to 
bone,  and  perichondrium  to  cartilage ;  and  when  the  former  is 
removed,  either  by  abrasion,  the  rupture  of  pustules,  or  destroyed 
by  chemical  agents,  a  portion  of  the  cornea  being  exposed,  some- 
times dies,  and  is  removed  by  absorption,  leaving  an  ulcer.  Ul- 
cers are  also  produced  by  mechanical  injuries;  but  wounds  of 
the  cornea  often  heal  without  ulceration,  the  healing  process 
being  at  once  established.     The  shape  and  appearance  of  ulcers 
are  very  various,  sometimes  appearing  like  little  excavations, 
with  little  or  no  surrounding  opacity ;  most  generally,  however, 
lymph  is  effused  around  them,  and  at  their  base.     Mr.  Vetch* 
says  that  they  have  a  disposition  rather  to  spread  than  to  deepen; 
while  Mr.  Wardropt  asserts  that  they  are  more  apt  to  increase  in 
depth  than  in  breadth.     The  fact  seems  to  us  to  be,  that  when 
the  sides  of  the  ulcer  are  not  limited  by  coagulable  lymph,  they 
spread  more  readily  than  they  penetrate,  but  when  lymph  is  de- 
posited on  the  sides,  it  seems  to  arrest  their  spreading,  and  they 
deepen  most  readily  until  they  arrive  at  the  inner  lamina  of  the 
cornea,  which  being  less  disposed  to  ulcerate  than  the  others,  the 
progress  of  the  ulcer  is  now  for  a  time  arrested,  but  if  the  dis- 
position to  disease  is  not  removed,  this  check  is  but  temporary, 
and  the  ulceration   may  spread  or  deepen,  or  both,  the  internal 
membrane  not  affording  any  effectual  barrier  to  the  ulcerative 
process. 

1240.  As  soon  as  the  internal  lamina  is  sufficiently  thin  and 
weakened  by  the  ulceration,  which,  when  the  ulcer  is  broad,  soon 
happens,  it  is  pushed  forwards  by  the  pressure  of  the  aqueous  hu- 
mour, or  when  the  ulcer  is  narrow,  this  lamina  may  ulcerate 
through,  and  the  serous  internal  membrane  is  protruded  in  the 
form  of  a  transparent  vesicle,  which  soon  ruptures,  and  the  aque- 
ous humour  is  discharged.     If  the  ulcer  be  within  the  limits  of 
the  iris,  this  part  floats  forward,  and  partially  or  completely  closes 
the  rupture;  coagulable  lymph  is  secreted,  uniting  the  iris  with 

*  Op.  Cit.  f  Op.  Cit.  Vol.  I. 


DISEASES    OP    THE    EYES.  371 

the  edge  of  the  ulcer,  and  closing  the  opening.  The  aqueous  hu- 
mour, however,  being  rapidly  regenerated,  before  the  breach  is 
repaired  or  sufficiently  strengthened  to  resist  pressure,  a  rupture 
again  takes  place,  and  the  humour  is  evacuated  ;  and  this  is  fre- 
quently repeated  before  a  sufficient  quantity  Of  lymph  is  effused 
to  render  the  breach  strong  enough  to  support  the  pressure  of 
the  aqueous  humour.  When  the  ulcer  is  near  the  centre,  the 
rupture  takes  place  more  frequently,  as  the  iris  cannot  assist  in 
closing  the  breach.  After  the  protruded  membrane  is  sufficiently 
strengthened  by  the  lymph  to  sustain  the  pressure,  it  is  then 
pushed  forward,  and  with  it  the  iris,  when  the  two  have  become 
adherent.  A  complete  hernia  is  thus  formed,  the  pressure  of  this 
upon  the  sides  of  the  ulcer  causes  their  absorption,  and  the  tu- 
mour thus  gradually  enlarges  till  it  sometimes  occupies  nearly 
the  whole  cornea.  The  tumour  at  its  commencement,  when  the 
iris  is  connected  with  it,  is  black  ;  when  not,  it  is  transparent 
and  colourless;  as  it  advances  it  becomes  opaque,  whitish  if 
the  iris  be  not  connected  with  it,  while  under  opposite  circum- 
stances it  has  a  beautiful  bluish  appearance ;  the  cause  of  this 
•colour,  so  different  from  that  of  either  the  cornea  or  iris,  has 
never  been  explained. 

1241.  When  inflammation  of  the  cornea  occurs  in  persons  of 
depraved  constitutions — in  those  who  have  recently  lost  much 
blood,  as  for  the  cure  of  acute  inflammation — or  in  children  im- 
perfectly nourished,  the  power  of  the  arteries  often  appears  to  be 
extremely  diminished,  they  do  not  perform  their  natural  office 
of  deposition  with  their  wonted  vigour,  whilst  the  action  of  the 
absorbents  continues  as  usual,  or  is  even  increased.     In  such  cases 
more  being  removed  by  the  absorbents  than  is  deposited  by  the 
arteries,  interstitial  ulcers  from  pure  ulcerative  absorption 
occur,  and  the  cornea  remains  transparent,  but  indented  or  pit- 
ted, according  as  the  ulcers  are  diffused  or  circumscribed.  When 
the  arteries  are  restored  to  their  healthy  action  lymph  is  depo- 
sited, which  fills  up  the  breach,  and  the  ulcer  is  healed. 

1242.  If  the  inflammation  in  such  individuals  be  very  intense, 
the  arteries  lose  their  powers  entirely ;  the  vitality  of  portions 
of  the  cornea  are  lost — and  the  contiguous  parts  are  removed  by 
the  absorbents — the  dead  portion  is  cast  off  as  a  slough,  and 
lamina  after  lamina  thus  slough  away.    This  occurs,  besides  un- 
der the  circumstances  noticed,  in  those  in  whom  the  parts  have 
been  weakened  by  previous  repeated  attacks  of  inflammation, 
and  very  frequently  after  the  sloughing  of  the  conjunctiva,  which 
sometimes  succeeds  purulent  inflammation  of  that  membrane, 
and  the  cornea  then  presents  that  peculiar  appearance  designated 
by  Mr.  Saunders,  by  the  terms  "  cindry,  ragged,  flocculent." 
When  restoration  occurs,  it  takes  place,  as  in  common  ulceration, 


372  DISEASES   OF   THE   EYES. 

by  the  deposition  of  lymph,  the  excess  of  which  is  absorbed,  and 
the  transparency  of  the  cornea  is  sometimes  restored,  even  where 
a  considerable  portion  of  ft  had  been  destroyed.  Mr.  Travers* 
says,  that  if  the  inflammation  be  arrested  even  on  the  verge  of 
gangrene,  the  cornea  i«  susceptible  of  restoration  by  absorption. 
"This  fact,"  he  ad^s,  "I  had  lately  an  opportunity  of  establish- 
ing in  the  case  of  a  lady  who  was  rendered  blind  by  acute  sup- 
purative  inflammation  of  the  conjunctiva;  so  inevitable  to  all  ap- 
pearance was  the  destruction  of  the  cornea,  which  had  sloughed 
in  a  deep  sulcas  at  its  junction  with  the  sclerotic  above,  that  the 
most  experienced  practitioner  of  my  acquaintance  in  this  branch 
of  surgery,  pronounced  the  case  hopeless  and  irremediable,  and 
took  his  leave.  The  highest  tonic  regimen,  bark,  wine,  and 
opium,  followed  close  upon  a  very  active  and  bold  depletion, 
and  the  anterior  chamber  was  fortunately  and  unexpectedly  pre- 
served. No  sooner  was  a  sign  of  the  arrest  of  sloughing  ulcera- 
tion  obtained  than  I  commenced  a  mercurial  course;  in  three 
days  the  system  was  affected ;  the  recovery  of  the  figure,  and 
transparency  of  the  cornea  was  rapid  and  complete  beyond  all 
expectation,  and  an  equally  perfect  state  of  vision  was  restored 
and  established." 

1243.  The  gangrenous  opacities  of  the  cornea,  says  Mr.  Tra- 
vers,t  produced  by  lime  or  other  substances  destroying  its  tex- 
ture, are  sometimes  superficial  and  defined  in  extent,  and  a  pro- 
cess resembling  exfoliation  ensues.    More  frequently  this  disor- 
ganization is  integral  and  complete.     The  cornea,  disorganized 
by  acids  is  rendered  instantly  opaque,  shrivelled,  and  of  a  yellow 
colour,  almost  resembling  a  piece  of  wash  leather. 

Treatment. 

1244.  Ulceration  of  the  cornea  being  the  effect  of  inflamma- 
tion, where  this  condition  is  still  present,  the  first  indication  is 
of  course  to  remove  it,  and  this  is  to  be  accomplished  by  the 
means  already  pointed  out  in  speaking  of  the  inflammation  of 
this  part.     Acute  pain,  lachrymation,  and  photophobia,  often 
accompany  ulcers  of  the  cornea,  and  where  these  are  not  re- 
moved by  the  ordinary  remedies,  temporary  benefit  will  be  ob- 
tained from  fomentations,  but  the  greatest  relief  will  be  expe- 
rienced  from  touching  the  ulcer  with  a  fine-pointed  pencil  of 
nitrate  of  silver,  so  as  to  produce  an  eschar.     After  the  inflam- 
mation is  subdued  in  ordinary  cases,  the  disposition  to  ulceration 
ceases,  granulations  form,  and  the  process  of  restoration  takes 
place;  should  this  flag,  stimulants  ought  to  be  applied,  and  the 

*  Op.  Cit.  p.  119.  f  Op.  Cit  p.  170. 


DISEASES    OP    THE    EYES.  373 

best  of  these  is  the  nitrate  of  silver.     Where  the  inflammation 
has  been  very  intense,  and  it  is  found  difficult  entirely  to  over- 
come it,  the  combination  of  nitre,  calomel,  and  tartar  emetic 
should  .be  administered;  or  if  this  state  be  accompanied  with 
much  pain,  the  blue  pill  and  opium  may  be  given.     When  the 
ulcer  penetrates  deeply  into  the  cornea,  and  the  internal  lamina, 
or  its  internal  lining  membrane  are  protruded  by  the  pressure  of 
the  aqueous  humour;  this  protrusion  should  be  touched  with  the 
fine  pencil  of  lunar  caustic,  by  which  means,  together  with  ac- 
tive antiphlogistic  measures,   especially  topical  depletion  and 
purgatives,  and  blisters  to  the  back  of  the  neck,  the  further  ex- 
tension of  the  ulceration,  and  the  evacuation  of  the  aqueous  hu- 
mour may  be  prevented.     Should,  however,  these  means  fail, 
and  the  ulcer  penetrate  the  cornea,  if  the  opening  be  small,  and 
opposed  to  the  iris,  the  further  escape  of  the  aqueous  humour 
will  be  prevented  ;  and  by  the  further  employment  of  antiphlo- 
gistics,  the  progress  of  ulceration  may  be  arrested,  and  restora- 
tion take  place.     The  iris  is  however  adherent  to  the  cornea  by 
the  lymph  effused  during  the  healing  process,  and  its  actions  de- 
ranged.    This  may  be  often  restored  by  promoting  the  absorp- 
tion of  the  lymph,  by  putting  the  system  under  the  mercurial 
influence  and  by  applying  belladonna  to  the  lids  and  brow.  When 
the  aperture  made  by  the  ulceration  is  large,  a  portion  of  the  pu- 
pil is  usually  prolapsed,  and  a  true  hernia  of  the  iris  takes  place, 
generally  attended  with  extreme  pain  from  the  stricture.     This 
is  to  be  relieved  by  the  free  application  of  the  pencil  of  nitrate 
of  silver  so  as  to  destroy  the  vitality  of  the  part.     When  the 
slough  separates,  a  fresh  portion  of  the  iris  will  be  protruded, 
and  this  is  to  be  treated  in  the  same  way,  and  the  operation  re- 
peated till  the  pain  ceases  and  restoration  takes  place.     The  iris 
in  this  case  is  permanently  injured,  and  the  pupil  usually  closed. 
If  the  prolapsed  iris  has  been  neglected  in  the  first  instance,  it 
may  increase  in  growth  and  assume  a  malignant  action;  it  should 
then  be  removed  by  scissors,  and  the  cut  surface  and  margin  of 
the  ulcer  freely  touched  with  the  nitrate  of  silver.  When  the  cor- 
nea becomes  disorganized  and  prominent,  no  attempt  at  effecting 
restoration  will  be  successful.     If  the  prominence  is  not  very 
considerable,  and  no  irritation  results  from  it,  it  had  better  be 
left  undisturbed ;  but  when  it  is  so  great  as  to  prevent  the  clo- 
sure of  the  eyelids,  occasion  great  deformity,  or  be  productive 
of  habitual  irritation  of  the  edges  of  the  eyelids,  it  should  be  ex- 
cised, after  which  the  humours  will  usually  escape  and  the  globe 
collapse.     The  excision  may  be  most  conveniently  performed  by 
passing  a  needle  with  a  ligature  across  the  cornea  to  steady  the 
eye ;  the  protrusion  may  then  be  divided  with  a  large  cornea 
knife,  and  if  the  whole  be  not  divided,  the  remaining  portion 


374  DISEASES    OP    THE    EYES. 

may  be  cut  with  a  pair  of  scissors.  A  compress  of  soft  linen  should 
then  be  applied  to  the  eye  and  retained  by  a  roller. 

1245.  In  interstitial  ulcers  the  indication  is  to  excite  the  ac- 
tion of  the  arteries,  which  is  to  be  fulfilled  by  the  use  of  topical 
stimulants,  as  a  solution  of  nit.  argent.,  sulph.  of  copper,  or  vi- 
num  opii,  and  nutritive  diet  and  tonics,  as  the  sulphuric  or  ni- 
tric acid,  and  bark.     As  soon  as  the  restorative  action  com- 
mences, it  will  be  perceived  by  a  whiteness  of  the  ulcer  and 
slight  cloudiness  of  the  surrounding  parts,  denoting  the  adhesive 
process. 

1246.  In  the  treatment  of  sloughing  ulceration  of  the  cornea, 
a  discriminating  judgment  and  close  observation  will  constantly 
be  required.     In  healthy  constitutions  the  most  prompt  and  vi- 
gorous antiphlogistic  measures  will  be  demanded  in  the  com- 
mencement, and  at  the  same  time  the  ulcer  should  be  touched 
with  the  pencil  of  nitrate  of  silver;  it  will  subsequently  be  often 
necessary  to  allow  nourishing  diet  and  tonics.  When  the  slough- 
ing process  is  arrested  by  these  means,  mercury  will  in  many 
cases  complete  the  cure.     In  debilitated  and  depraved  constitu- 
tions, nourishing  diet  and  tonics  will  often  be  demanded  from  the 
very  commencement;  but  at  the  same  time,  when  there  is  much 
local  inflammation,  topical  depletion  should  be  employed,  and 
afterwards  the  ulcer  should  be  touched  with  the  solid  nitrate  of 
silver,  and  when  the  healing  process  commences,  the  solution 
should  be  applied  several  times  a  day.     When  the  ulcer  pene- 
trates the  cornea,  the  local  applications  already  recommended 
are  to  be  employed,  but  instead  of  antiphlogistics,  tonics  and 
nourishing  diet  are  to  be  prescribed. 

5.   Conical  Cornea. 

1247.  This  affection  of  the  cornea  was  not  described  until 
within  a  few  years  past,  and  as  we  have  never  met  with  an 
instance  of  it,  we  shall  transcribe  the  account  given  of  it  by 
Mr.  Travers.*     "  The  cornea  is  occasionally  subject  to  a  pro- 
cess of  thinning  or  absorption  of  its  interlamellar  texture,  and  in 
consequence  loses  its  natural  tonic  resistance  to  the  pressure  of 
the  contents  of  the  globe.     It  usually  assumes  a  conoidal  figure, 
but  this  is  not  always  the  case ;  the  projection  of  the  cornea  is 
sometimes  uniform,  describing  the  segment  of  a  larger  sphere. 
The  apex  of  the  cone  corresponding  to  the  centre  of  the  cornea, 
when  this  figure  is  assumed,  exhibits  a  degree  of  tenuity  and  bril- 
liancy which  gives  it  the  appearance  of  a  pellucid  fluid,  like  a 
dew-drop  suspended.     The  patient's  vision  becomes  so  inconve- 

*  Op.  Cit.  p.  124. 


DISEASES   OF    THE    EYES.  373 

niently  short,  as  to  render  objects  confused  at  a  very  moderate 
distance;  the  change  is  sometimes  slow,  occupying  months  and 
even  years,  and  on  the  contrary  I  have  seen  it  produced  in  its 
greatest  extent  in  the  short  space  of  eight  weeks;  both  eyes  are 
generally  affected,  though  not  always  in  the  same  degree.  The 
disease  is  not  produced  by  inflammation  or  any  obvious  assign- 
able cause;  it  is  more  frequent  in  women  than  in  men,  and  in  my 
experience  affects  the  periods  of  youth  and  middle  life ;  I  have 
never  seen  it  commencing  in  infancy  or  old  age.  It  is  as  much 
the  disease  of  the  robust,  as  of  the  weakly  constitution  and  frame 
of  body." 

1248.  A  variety  of  remedies  have  been  tried  for  the  cure  of 
this  affection,  such  as  frequent  cupping,  issues,  evacuating  the 
aqueous  humour,  all  however  without  success.  A  pupillary  aper- 
ture, set  in  a  black  ring  frame,  about  a  quarter  of  an  inch  or 
more  in  depth,  when  the  convexity  is  not  very  much  increased, 
by  confining  the  rays  of  light  to  the  central  portion  of  the  cor- 
nea, and  preventing  the  confusion  from  the  unnatural  refraction 
of  the  lateral  rays,  will  sometimes  considerably  assist  vision. 

6.  Encysted  Tumours  in  the  Lamellae  of  the  Cornea. 

1249.  These  were  first  observed  by  Dupuytren  in  the  case  of 
a  child  who  had  been  struck  on  the  eye  some  weeks  before  by  a 
stone.  At  first  view  he  conceived  it  to  be  an  opacity  of  the  cor- 
nea, but  a  more  minute  inspection  showed  it  to  be  a  serous  en- 
cysted tumour  existing  between  the  lamellae  of  that  coat.  He  in- 
troduced a  cataract  needle  into  the  small  cyst,  and  moved  the 
instrument  up  and  down  in  order  to  irritate  its  inner  surface. 
The  fluid  in  the  tumour  was  evacuated,  but  in  fourteen  days  it 
formed  again.     The  operation  was  repeated,  and  adhesion  of  its 
sides  took  place,  but  opacity  of  the  cornea  resulted.     No  other 
surgeon  has,  we  believe,  noticed  these  tumours,  and  little  is  known 
respecting  them. 

7.  Ossification  of  the  Cornea. 

1250.  The  vessels  of  the  cornea,  like  those  of  the  other  fibro- 
cartilages,  in  some  few  instances  secrete  osseous  matter.     Mr. 
Wardrop*  has  met  with  it  on  one  occasion ;  in  this  the  form  of 
the  whole  eye  was  changed,  the  cornea  had  became  opaque,  and 
on  macerating,  a  piece  of  bone  weighing  two  grains,  oval-shaped, 
hard,  and  with  a  smooth  surface,  was  found  between  its  lamella.' 
It  is  mentioned  in  the  Nouvelle  JSibliotheque  Medicale,  for 

*  Op.  Cit.  p.  72. 


376  DISEASES    OP   THE  EYES. 

May,  1817,  that  the  eye  of  an  old  man  had  been  recently  pre- 
sented to  the  Societ6  Anatomique  by  M.  Monot,  in  which  the 
cornea  was  ossified  throughout. 

§  III.  INFLAMMATION  OP  THE  SEROUS  LINING  MEMBRANE  OF 
THE  CORNEA. 

1251.  Inflammation  of  this  tunic,  independent  of  that  of  the 
cornea,  is  of  too  unfrequent  occurrence  to  enable  us  to  ascertain 
very  minutely  its  progress  and  terminations,  but  as  far  as  our 
observation  goes,  they  are  similar  to  those  of  other  serous  tis- 
sues.    In  the  following  case  we  are  enabled  to  observe  this  affec- 
tion with  great  advantage,  as  it  was  uncomplicated  with  inflam- 
mation of  the  cornea. 

1252.  Eliza  Williams,  a  coloured  woman,  aged  twenty,  ap- 
plied to  the  Pennsylvania  Eye  Infirmary,  April  6th,  1S26.   Her 
sight  had   been   growing  dim  for  several  days,  and  she  suffered 
slight  pain  in  her  eye.     On  the  most  minute  examination,  no 
change  from  a  healthy  state  could  be  perceived,  except  perhaps 
an  extremely  faint  dullness,  almost  imperceptible,  situated  at  the 
posterior  part  of  the   cornea,  the  cornea  itself  being  evidently 
unaffected.  After  some  days  a  small  spot  became  visible,  and  was 
shortly  followed  by  two  others,  differing  both  in  situation  and 
appearance  from  the  opacities  produced  from  inflammation  of  the 
cornea.   They  were  deep-seated,  and  evidently  produced  by  the 
effusion  of  lymph  on  the  inner  surface  of  the  cornea,  "giving  it 
the  appearance  of  being  mottled  with  white.  The  margins  of 
these  spots  were  well  defined,  and  the  lamina  of  lymph  so  thin 
as  not  to  produce  perfect  opacity. 

Treatment. 

1253.  The  treatment  we  employed  in  this,  and  which  we 
would  recommend  in  similar  instances,  was  the  employment  of 
antiphlogistics,  to  prevent  effusion,  and  to  put  the  system  under 
the  mercurial  influence,  to  promote  absorption  after  this  had 
taken  place.     In  the  case  we  have  described,  owing  to  peculi- 
arity of  constitution,  this  latter  could  not  be  persevered  in  to  a 
sufficient  extent,  and  the  spots  have  remained  permanent. 


DISEASES    OF    THE    TRACHEA    AND    THORAX.  377 

CHAPTER  X. 

DISEASES  OF  THE  TRACHEA  AND  THORAX. 

1254.  THE  variety  of  affections  of  the  chest,  to  which  inflam- 
mation gives  rise,  renders  their  history  highly  important  to  the 
practitioner.     Until  lately,  too  little  interest  has  been  felt  upon 
this  subject  by  medical  men  ;  not  because  they  were  ignorant  of 
its  importance  to  their  patients,  or  indifferent  to  the  interests  of 
their  profession,  but  because  there  was  but  one  mode  of  ascer- 
taining the  condition  of  the  contents  and  lining  of  the  thorax; 
namely,  by  a  post  mortem  examination,  and  by  this  they  could 
profit  but  little,  as  the  several  diseases,  or  rather  the  conse- 
quences of  inflammation  of  these  parts,  had  no  clear  and  de- 
cided diagnostic  symptoms,  by  which  they  could  discriminate 
one  affection  from  the  other  during  the  lifetime  of  the  patient. 
Neither  could  they  ascertain  the  various  terminations  or  conse- 
quences of  inflammation,  as  it  might  attack  one,  or  several  of 
the  tissues  composing  the  internal  surface  of  the  thorax,  or  of 
the  parenchyma  of  either  of  its  viscera. 

1255.  These  difficulties  to  the  investigation  of  the  affections 
of  the  chest,  no  longer  exist;  nor  can  the  same  excuses  be  made; 
for  now,  a  certain  and  accurate  method  is  discovered,  whereby 
every  deviation  of  healthy  structure  can  be  ascertained  with  an 
exactness  that  can  scarcely  be  credited  by  those,  who  have  not 
witnessed  the  results  of  stethoscopic  or  auscultic  examinations. 
The  number  of  pathological  changes  produced  by  inflammation, 
which  the  stethoscope  reveals  to  the  experienced  ear  with  an 
almost  absolute  certainty,  far  exceeds  what  is  generally  imagined, 
or  could  well  be  believed.     Almost  all  the  diseases  of  the  chest, 
and  especially  such  as  were  attended  by  cough  and  expectora- 
tion, (and  they  nearly  all  were  accompanied  by  these,)  were 
called  phthisis,  or  consumption;  but  late  pathological  researches 
have  discovered  a  great  variety  of  changes  in  the  structure  and  con- 
dition of  the  tissues  of  the  thorax,  after  they  have  been  subjected 
to  inflammation,  or  during  its  actual  existence  and  progress.  It  is 
scarcely  necessary  to  say,  how  important  these  discoveries  are 
to  the  practical  physician.*     These  considerations  have  led  us  to 

*  "  Auscultation  may  be  said  to  have  disclosed  a  new  and  very  direct  source  of 
pathological  investigation  in  a  class  of  diseases,  the  diagnoses  of  which  have 
hitherto  been  involved  in  much  obscurity  and  uncertainty  ;  and  in  which  any 
means  of  acquiring,  during  life,  additional  information  on  these  essential 

48 


378  DISEASES    OF    THE    TBACHEA    AND    THORAX. 

a  more  extensive  investigation  of  this  subject,  than  we  had  ori- 
ginally contemplated — its  importance  we  are  certain  will  justify 
our  plan. 

1256.  It  may  be  useful  to  state,  that  the  objections  we  have 
heard  urged  against  the  study  of  the  diseases  of  the  chest,  by 
percussion,  and  mediate,  and  immediate  auscultation,  have  been, 
1st,  the  difficulty  of  acquiring  such  a  degree  of  knowledge  of  it 
as  shall  be  practically  useful.  This  we  are  aware,  has  prevented 
many  from  pursuing  this  important  inquiry;  but  that  this  ob- 
jection is  not  well  grounded,  may  we  think  be  safely  inferred 
from  the  observations  of  Dr.  Williams  and  Dr.  Townsend ;  the 
former  has  written  a  short,  but  valuable  work  entitled,  "A  Ra- 
tional Exposition  of  the  Physical  Signs  of  the  Diseases  of  the 
Lungs  and  Pleura."     And  perhaps  few  are  better  qualified  to 
judge,  or  to  teach,  upon   this  subject,  as  he  informs  us  with  as 
much  modesty  as  candour,  that  his  "  acquaintance  with  the  phy- 
sical signs"  (of  the  diseases  of  the  chest,)  **  is  the  result  of  some 
extent  of  study  and  observation,  prosecuted  in  the  wards  of  La 
Charite,  where  Laennec  taught,  and  Andral  prosecuted  his  la- 
bours;" thus  tacitly  acknowledging  his  obligations  to  these  ex- 
perienced practitioners,  for  the  information  he  possessed  upon 
the  subjects  on  which  he  has  written;  but  in  no  part  of  his  works, 
does  he  acknowledge  the  difficulty  above  stated. 

1257.  In  his  preface  he  makes  some  important  and  judicious 
observations  on  the  nature  and  value  of  auscultation  and  percus- 
sion, some  of  which  we  feel  it  will  be  proper  to  give  in  his  own 
words;  and  we  shall  emphatically  mark  such  as  we  deem  most 
useful. 

1258.  He  tells  us,  p.  viii.  that,  "  the  local  study  of  diseases 
must  not  remove  our  attention  from  their  general  phenome- 
na; our  examination  of  their  physical  nature  must  not  ex- 
clude the  consideration  of  many  constitutional  effects,  that 
by  reaction  may  be  converted  into  causes ;  and  still  less  should 
physical  signs  of  doubtful  import  make  us  neglect  obvious 
disorder  of  the  system."     This  distinctly  proves  the  necessity 
and  propriety  of  attending  to  the  constitutional  phenomena  of 
diseases. 

1259.  Again,  "  Thus  limited,  the  local  study  of  diseases  is 
more  advantageous  than  the  knowledge  of  their  general  forms ; 
an  examination  of  their  physical  signs,  when   possible,   more 
useful  than  the  perplexing  consideration  of  a  host  of  uncertain 
and  fallacious  constitutional    symptoms;    and  when  physical 

points,  ought  to  be  the  more  important,  as  that  obtained  by  the  other  senses 
is,  and  must  always  be,  so  scanty  and  unsatisfactory."  Dr.  Gregory  on  the  Di- 
agnosis of  the  Diseases  of  the  Lungs  and  Pleura.  Edinb.  Med.  and  Surg. 
Jour,  for  July,  1830,  p.  36. 


DISEASES    OF    THE    TRACHEA    AND    THORAX.  379 

signs  are  wanting,  or  beyond  the  sphere  of  our  observation, 
these  constitutional  ones  are  our  best  guides,  which  most 
nearly  depend  on  the  physical  and  unchangeable  character  of 
the  disease.  For  the  local  study  of  a  disease  acquaints  us  with 
its  proximate  and  essential  cause,  and  this  knowledge  sug- 
gests means  for  its  removal;  and  by  a  study  of  its  physical 
signs,  and  of  those  general  ones  most  allied  to  them,  we  obtain 
the  most  certain  method  of  discovering  its  existence,  and  of  dis- 
tinguishing its  character."* 

1£60.  The  second  objection  urged  against  this  study  is,  "  that 
it  is  impossible  to  convey,  by  description,  an  accurate  idea  of 
sounds."  To  remove  this  objection,  we  shall  only  quote  the 
words  of  Dr.  Townsend  upon  this  point.! 

1261.  "I  know  that  it  has  been  often  urged  as  an  objection 
to  the  use  of  the  stethoscope,  that  it  is  impossible  to  convey  by 
description  an  accurate  idea  of  sounds ;  and  that  for  this  reason, 
none  but  those  persons  who  have  studied  under  the  author  of 
mediate  auscultation,  can  be  sure  that  they  refer  each  sound  to 
its  proper  denomination.  I  can  only  reply  to  this  objection  by 
stating,  that  although,  during  my  attendance  on  the  wards  of 
Mr.  Laennec,  I  never  had  an  opportunity  to  study  these  sounds, 
(the  tintement  metallique  and  bourdonnement  amphorique,) 
yet  so  precisely  did  they  answer  his  description,  that  I  felt  not 
the  least  difficulty  in  recognising  them ;  and  so  perfectly  was  I 
convinced  of  their  identity,  that  I  hesitated  not,  on  the  sounds  I 
had  never  heard  before,  to  pronounce  on  the  existence  of  a  mor- 
bid lesion  I  had  never  previously  seen,  and  I  appeal  to  the  re- 
sult, if  my  confidence  was  not  justified."  And  as  perhaps  no 
case  can  better  illustrate  the  accuracy  of  diagnosis  by  the  stetho- 
scope than  one  of  those  related  in  the  work  above  named,  we 

*  Dr.  Forbes,  with  a  view  to  prevent  an  exclusive  reliance  upon  the  physi- 
cal signs  presented  by  percussion  and  auscultation,  says,  "  I  think  it  highly 
necessary,  in  this  place,  to  caution  the  student  against  yielding  too  implicit 
confidence  to  auscultation  and  percussion,  as  means  of  diagnosis,  to  the  ne- 
glect or  exclusion  of  the  more  usual  methods.  It  is  no  doubt  true,  that  these 
measures  are  of  the  very  first  importance  in  the  diagnosis  of  this,  as  of  almost 
every  other  disease  of  the  chest ;  that  in  many  cases  they  alone  suffice  to  fix 
the  diagnosis  ;  and  that  in  others  this  cannot  be  established  without  them  :  at 
the  same  time,  it  is  equally  certain,  that  if  we  attempt,  as  our  general  prac- 
tice, to  draw  our  conclusions,  from  these  signs  alone,  without  reference  to  the 
general  and  local  symptoms,  we  shall  frequently  not  merely  fail  to  attain  our 
object  at  all,  but  we  shall  run  into  the  risk  of  falling  into  errors  of  the  most  se- 
rious nature.  It  is  only  by  combining  the  practice  of  auscultation  with  the 
faithful  observation  of  symptoms,  and  by  studying  the  results  obtained  from 
both  sources,  with  a  reference  to  the  pathology  of  the  disease,  that  we 
can  hope  to  attain  to  such  a  certainty  of  diagnosis,  as  can  satisfy  a  philosophi- 
cal mind." 

f  See  his  excellent  cases  in  the  Transactions  of  the  King  and  Queen's  Col- 
lege of  Physicians  in  Ireland. 


DISEASES  OP    THE    TRACHEA    AND    THORAX. 

shall  take  the  liberty  of  giving  it  as  an  instance  of  valuable  il» 
lustration  of  what  we  wish  to  enforce  by  these  observations — 
namely,  the  accuracy  and  importance  of  stethoscopic  examina- 
tions in  the  affections  of  the  chest;  and  at  the  same  time  to 
recommend  the  study  of  auscultation  to  every  practical  physi- 
cian, be  his  experience  and  tact  what  they  may,  in  the  general 
phenomena  and  constitutional  effects  of  disease.  Indeed,  to  him 
who  is  best  acquainted  with  these  latter  phenomena,  the  study 
of  auscultation  will  be  increased  in  value,  besides  being  of  more 
easy  attainment. 

1262.  "A  tall,  well-proportioned  dragoon,  was  attacked  in 
October,  1826,  with  cough,  pain  in  the  chest,  and  diarrhoea,  for 
which  he  was  bled,  blistered,  &c.     A  recurrence  of  the  same 
symptoms  called  for  a  repetition  of  these  measures,  which,  as 
well  as  several  others  afterwards  employed,  failed  to  produce 
any  permanent  advantage."     Dr.  Townsend  saw  him  March  25, 
1827,  at  which  time  he  was  up  and  dressed  ;  "walked  about  the 
room,  but  was  soon  out  of  breath,  and  easily  fatigued.     He  was 
considerably  emaciated,  had  much  dyspnoea,  not  sufficient,  how- 
ever, to  materially  affect  his  speaking,  profuse  night  sweats,  di- 
arrhoea, thirst,  anorexia;  pulse  120,  small  and  vibratory;  num- 
ber of  respiration  30;  cough  most  troublesome  on  waking  in  the 
morning ;  sputa  apparently  mucus ;  are  stated  to  have  diminished 
considerably  in  quantity  within  the  last  three  weeks,  from  which 
period  is  also  dated  the  aggravation  of  his  dyspnoea.  On  viewing 
the  thorax,  the  right  side  appeared  considerably  more  dilated 
than  the  left,  especially  anteriorly  and  laterally  at  its  lower 
half.     Percussion  employed  over  the  dilated  surface  elicited  a 
clear  hollow  sound.     In  this  space,  too,  the  respiratory  murmur 
was  perfectly  inaudible;  but  immediately  after  coughing,  a  pe- 
culiar sound,  resembling  the  vibrations  of  a  porcelain  jar,  when 
generally  struck,  (tintement  metallique,)  was  distinctly  heard 
in  a  space  corresponding  to  the  posterior  convexities  of  the 
sixth,  seventh,  and  eighth  ribs.     The  sound  was  not  produced 
either  by  respiration  or  speaking.    Succussion  did  not  produce 
the  sound  of  fluctuation,  although  the  patient  said  he  felt  water 
dashing  against  his  side.     In  the  superior  part  of  the  same  side 
of  the  chest,  (the  right,)  the  dilatation  was  scarcely,  if  at  all  per- 
ceptible.    The  sound  on  percussion  not  particularly  sonorous, 
and  the  respiratory  murmur  audible  posteriorly." 

1263.  "  At  the  left  side,  the  sound  on  percussion  was  natural, 
though  considerably  duller  than  at  the  right.     Respiration  was 
distinctly  audible  all  over  the  lung's  surface,  except  in  the  space 
corresponding  to  the  superior  lobe,  where  cavernous  respiration 
with  perfect  pgctoriloquy  were  heard  distinctly." 

1264.  "Diagnosis.  A  tubercular  cavity  occupies  the  upper 


i 

• 

.   •**.<••• 


DISEASES    OF    THE    TKACHEA    AND    THOKAX.  381 


lobe  of  the  left  lung.  The  dilatation  of  the  right  side  of  the  chest 
is  produced  by  pneumothorax,  and  the  coexistence  of  the  tinte- 
mtnt  metalligue,  proves  that  the  air  of  the  pleura  proceeds  from 
a  communication  between  the  bronchia  and  the  pleura.  The 
medium  of  communication  in  this  case,  I  conceive  to  be  a  tuber- 
cular cavity  in  the  opposite  lung,  converts  the  probability  of  this 
species  of  abscess  into  a  moral  certainty,  of  which  no  doubt  could 
have  existed,  if  the  patient  had  been  examined  by  the  stetho- 
scope, and  pectoriloquy  found  under  the  right  clavicle,  before 
the  accession  of  pneumothorax.  I  attribute  the  comparatively 
dull  sound  on  percussion,  on  the  superior  part  of  the  thorax,  and 
its  less  degree  of  dilatation  to  the  existence  of  ancient  adhesions, 
which  prevented  the  air  accumulating  in  that  region,  between 
the  pleura  costalis  and  pulmonalis." 

1265.  "  To  recapitulate. — The  lesions  I  expect  to  find  are,  a 
tubercular  cavity  in  the  upper  lobe  of  the  left  lung;  the  right 
side  of  the  thorax  distended  with  air  and  fluid,  (the  latter  at  pre- 
sent exists  in  small  quantity,  but  its  proportion  will  no  doubt  go 
on  increasing;)  in  the  right  lung  a  tubercular  cavity  communi- 
cating with  the  sac  of  the  pleura  on  the  one  hand,  and  with  the 
bronchia  on  the  other,  allowing  the  air  inspired  to  pass  freely 
into  the  pleura;  and  finally,  the  superior  lobe  united  by  old  ad- 
hesions to  its  Corresponding  costal  pleura.     This  detailed  diag- 
nosis was  written  and  handed  over  to  Dr.  Oheyne  on  the  evening 
of  my  first  visit." 

1266.  llMarch25th. — Had  no  sleep  last  night;  face  expressive 
of  considerable  suffering ;  a  bluish  tint  of  lips  and  nails  is  percep- 
tible.    Says  he  feels  no  pain  whatever.     Cough  peculiarly  deep 
and  hollow;  slight   mucous   expectoration.     At  the  right  side, 
sound  on  percussion  continues  hollow  inferiorly,  even  over  the 
region  usually  occupied  by  the  liver,  where  a  full  inspiration 
sounds  precisely  like  blowing  into  an  empty  bottle,   (bourdon- 
nement  amphoric.)  Speaking  as  well  as  coughing,  is  now  fol- 
lowed by  the  tintement  metallique.  In  the  superior  part  of  the 
thorax,  the  sound  on  percussion  is  clear  and  hollow  anteriorly, 
where  all  the  respiratory  murmur  is  extinct.  Quantity  of  ga- 
seous effusion  increases" 

1267.  "2Slh.  Does  not  recollect  any  sudden  aggravation  of  his 
symptoms  about  the  period  when  his  breathing  became  materially 
affected.     Never  suffered  much  pain  of  right  side ;  thinks  on  the 
whole  that  the  other  side  now  gives  him,  and  has,  for  the  last 
three  months,  the  greater  uneasiness  of  the  two.     Sits  up,  and 
walks  about.     Pulse  120;  respiration  36.  No  change  in  the  ste- 
thoscopic  sounds." 

1268.  "April  1st. — Pain  of  left  side  removed  by  the  applica- 
tion of  a  blister;  dyspnoea  increased  ;  number  of  respirations  38; 


382  DISEASES    OF    THE    TRACHEA    AND    THORAX. 

diarrhoea;  profuse  night  sweats.  At  the  right  side,  sound  on 
percussion  is  become  dull  posteriorly  in  the  space  corresponding 
to  the  inferior  portion  of  the  thoracic  cavity,  where  no  sound 
whatever  can  be  heard.  Fluid  accumulates.  Above  the  eighth 
rib,  the  sound  on  percussion  is  hollow;  the  ordinary  inspirations 
sound  like  blowing  into  a  bottle.  Expiration  is  followed  by  a 
musical  sound,  resembling  the  vibrations  of  a  fine  wire  chord. 
Coughing  produces  a  peculiar  sound;  exactly  similar  to  the  ring- 
ing of  a  porcelain  jar  ;  the  voice  much  more  obscurely  so.  On 
making  the  patient  sit  up  in  bed,  and  shaking  him  gently  by  the 
shoulder,  (the  stethoscope  being  applied  posteriorly  about  the 
convexity  of  the  seventh  rib,)  a  fluid  is  clearly  heard  dashing 
against  the  sides  of  the  thorax.  The  patient  is  sensible  of  this 
fluctuation,  says  he  hears  it,  though  /could  not  without  apply- 
ing my  ear.  When  he  suddenly  rises  from  the  recumbent  pos- 
ture, three  or  four  drops  are  heard  to  fall  successively  from  above 
on  the  surface  of  a  fluid.  This  sound  is  most  distinctly  heard 
over  the  seventh  rib  posteriorly.  In  the  left  lung,  pectoriloquy, 
&c.  as  before.  Feels  no  pain  whatever  in  right  side.  I,  in  con- 
sequence, added  to  my  former  diagnosis,  that  the  constant  ab- 
sence of  pain  proceeded  probably  from  a  thick  coating  of  albu- 
minous exudation,  the  product  of  previous  inflammation,  which 
lines  the  pleura,  and  defends  it  from  the  contact  of  air. " 

1269.  The  symptoms  gradually  became  aggravated,  and  on 
the  14th  there  were  "profuse  night  sweats,  colliquative  diarrhoea, 
stools  consisting  of  a  black  matter  resembling  coffee  grounds, 
great  prostration  of  strength,  increase  of  dyspnoea,  though  it 
never  became  extreme  up  to  the  time  of  his  death,  which  occur- 
red on  the  afternoon  of  this  day." 

1270.  "Dissection,  forty  hours  after  death. — External  ap- 
pearances.    Body  well  proportioned,  considerable  emaciation, 
legs  and  feet  slightly  cedematous  ;  the  right  side  appeared  consi- 
derably more  dilated  than  the  left,but  on  measuring  with  a  tape, 
the  greatest  difference  did  not  exceed  an  inch  and  an  half.     On 
employing  succussion,  fluctuation  was  heard  by  applying  the  ear 
to  the  chest,  but  was  not  audible  to  the  bystanders." 

1271.  "  Thorax. — The  right  side.  A  trocar  was  introduced 
between  the  fifth  and  sixth  ribs,  near  their  junction  with  their 
cartilages — an  immediate  rush  of  air  followed."  "  On  removing 
the  sternum,  a  vast  unoccupied  space  was  observed  in  the  ante- 
rior part  of  the  thorax,  capable  fully  of  holding  two  quarts  of 
fluid.     This  space  had  been  occupied  by  air,  which  by  conse- 
quence we  estimated  at  that  quantity.     The  lung  just  appeared 
above  the  fluid  which  occupied  the  posterior  region  of  the  tho- 
rax; it  was  closely  compressed  against  the  spine,  and  seemed 
reduced  to  one-third  its  natural  size.     The  fluid  effused,  might 


DISEASES    OP    THE    TRACHEA    AND    THORAX.  383 

be  in  quantity  about  two  quarts,  was  of  a  yellowish-green 
colour,  tolerably  clear  at  its  surface,  but  rendered  turbid  at  bot- 
tom by  numerous  fragments  of  opaque,  puriform  flocculi  of 
albumen." 

1272.  "  Before  touching  the  lung,  to  guard  against  an  acci- 
dental formation  of  the  opening  which  I  expected  to  find,  an  in- 
cision was  made  into  the  trachea,  and  the  pipe  of  a  pair  of  bel- 
lows introduced.  The  air  passed  freely  through  the  lung,  and 
appeared  in  bubbles  at  the  surface  of  the  fluid,  in  which  it  was 
immersed.  The  fluid  being  removed,  the  upper  lobe  of  the  lung 
was  found  in  close  contact  with,  and  firmly  attached  to  the  costal 
pleura.  The  whole  surface  of  the  lung,  except  what  was  attached, 
was  covered  with  an  albuminous  exudation  of  a  dirty  white  co- 
lour, of  several  lines  thickness,  its  surface  wrinkled  not  unlike 
the  rind  of  a  shrivelled  apple.  The  costal,  mediastinal,  and  dia- 
phragmatic pleuraj  were  still  more  thickly  coated  with  this  exu- 
dation, which,  though  strongly  attached  to  the  subjacent  pleurae, 
and  apparently  incorporated  with  it,  might  by  careful  dissection, 
be  separated  from  it,  leaving  the  membrane  underneath,  in  a 
state  of  perfect  integrity.  The  lung  was  now  detached,  on  its 
anterior  surface,  about  two  inches  from  the  summit  of  the  upper 
lobe,  was  discovered  a  fistulous  orifice,  capable  of  receiving  my 
little  finger,  its  margin  well-defined,  rounded,  and  nearly  carti- 
laginous. A  probe  introduced  passed  readily  through  a  series  of 
tubercular  cavities  into  one  of  the  principal  bronchia.  At  inter- 
vals of  half  an  inch  below  this  fistulous  orifice  existed  three 
small,  oval,  superficial  ulcers,  which,  on  close  examination,  did 
not  appear  to  communicate  with  the  bronchia.  They  were  evi- 
dently formed  by  softened  tubercles,  developed  immediately  un- 
der the  pleura;  for  on  different  parts  of  the  lung's  surface  there 
were  several  similar  oval  nests  of  tubercles,  some  not  yet  soften- 
ed, others  quite  soft,  and  elevating  the  pleura,  through  which 
they  had  not  as  yet  formed  a  passage.  Posteriorly  near  the  root  of 
the  lung,  and  about  the  base  of  the  superior  lobe,  immediately 
underneath  its  adhesion  to  the  pleura,  was  another  fistulous  pas- 
sage with  a  large  tubercular  abscess  occupying  nearly  the  whole 
upper  lobe.  This  passage  was  lined  all  through  with  a  highly 
vascular  membrane,  exactly  similar  to  that  which  lined  the  tuber- 
cular abscess,  having  its  surface  coated  with  a  layer  of  lymph. 
Into  this  vast  abscess  was  also  traced  one  of  the  principal  bron- 
chial divisions;  its  entry  into  the  cavity  was  within  a  few  lines 
of  that  of  the  sinous  passage  above  described.  The  middle  and 
lower  lobes  contained  several  tubercles.  The  bronchial  glands 
also  were  much  enlarged,  and  studded  with  tubercles." 

1273.   "The  left  side  of  the  chest— This  lung  was  studded 
throughout  with  granular  tubercles  of  the  size  of  duck-shot.     In 


384  CATARRH. 

the  superior  lobe  was  found  one  cavity,  capable  of  containing  a 
large  filbert,  and  communicating  with  two  or  three  smaller  ones. 
In  the  middle  lobe,  (the  left  lung  had  three  lobes,)  the  tubercles 
were  all  opaque  and  whitish.  In  the  inferior,  many  of  them 
were  in  the  first,  or  grayish,  semitransparent  stage." 

1274.  "  This  case  of  pleurisy,  with  pneumothorax,  differs 
from  any  other  that  I  have  seen  recorded,  in  the  total  absence  of 
pain  in  the  side  affected;  in  not  having  its  commencement  mark- 
ed by  any  sudden  or  violent  symptoms  of  dyspnoea  or  pain;  and 
also  in  this,  that  the  patient  was  able,  almost  to  the  time  of  his 
death,  to  dress  himself,  and  sit  up;  whereas  M.  Laennec  ex- 
pressly states,  in  all  the  cases  which  he  had  seen,  the  patients 
were  excessively  oppressed,  and  unable  to  quit  their  beds.  In- 
deed he  lays  down  these  circumstances,  as  adjuvant  diagnostic 
marks,  whereby  to  distinguish  this  disease  from  emphysema. 
But  in  this  instance  such  minor  distinguishing  features  were  not 
necessary.  The  great  distention  of  the  right  side  of  the  chest; 
its  remarkable  sonoriety;  the  total  absence  of  respiration,  unless 
where  the  lung  was  attached;  the  extraordinary  development  of 
the  pathognomonic  signs,  all  established  beyond  the  possibility 
of  doubt,  the  precise  nature  of  the  disease.  I  shall  only  add, 
that  the  dull  sound  supervening  interiorly,  and  gradually  ascend- 
ing, the  increasing  capacity  and  sonoriety  of  the  superior  part 
of  the  thorax,  together  with  the  increased  extent  of  surface  over 
which  the  pathognomonic  sounds  were  heard,  did  all,  and  each 
of  them,  mark  exactly  the  progress  of  the  disease  from  day  to 
day,  up  to  the  period  of  its  fatal  termination." 

1275.  We  trust  we  have,  in  what  we  have  just  said,  excited 
a  curiosity,  if  we  have  not  fixed  a  determination  in  the  mind  of 
the  reader,  to  investigate  the  claims  of  auscultation  to  his  serious 
attention ;  and  also,  that  we  have  introduced  a  case,  every  way 
illustrative,  of  the  accuracy  of  diagnosis  made  by  stethoscopic 
examinations.     The  several  terms  employed  in  illustrating  aus- 
cultation, will  be  found  explained  in  the  Glossary,  at  the  end  of 
the  volume. 

SECT.  I. — OF  CATARRH. 

1276.  This  common  affection,  or  "a  cold,"  as  it  is  commonly 
called,  in  its  simple,  or  uncomplicated  condition,  is  one  of  more 
inconvenience  than  of  danger.  It  is  of  such  frequent  occurrence, 
and  so  rarely  attended  with  danger,  or  even  pain,  that  the  phy- 
sician for  the  most  part,  is  not  called  upon  for  his  prescription. 
Indeed,  the  plan  of  treatment  for  its  cure,  is  by  most  people 
looked  upon  worse  than  the  disease  itself ;  and  thence,  its  tedious 
protraction  in  some  cases.     It  is  usually  more  severe  with  chil- 


CATAKKH.  385 

dren  than  with  adults  ;  owing  to  the  greater  susceptibility  of  the 
mucous  membrane  of  the  nose,  windpipe  and  the  lungs,  with  them, 
to  take  on  inflammation.  And  hence,  with  children,  it  often 
becomes  a  disease  of  great  severity,  and  sometimes  one  of  much 
danger;  hence,  we  are  called  more  frequently  to  their  aid,  than 
to  the  adult. 

1277.  This  complaint  almost  always  begins  by  a  sensation  of 
fulness  or  thickening  of  the  membrane  that  lines  the  nose ;  an  in- 
crease of  secretion  of  the  common  mucus  of  the  part  takes  place, 
though  somewhat  changed  in  its  character — that  is,  it  is  not  only 
thinner,  but  also  rather  acrid,  as  the  increased  vascular  condition, 
of  the  Schneiderian  membrane,  together  with  slight  excoriations 
of  the  most  depending  part  of  the  nostrils,  and  upper  portion  of 
the  upper  lip,  testify. 

1278.  This  condition  of  the  nostrils  continues  an  uncertain 
period,  according  to  the  force  of  the  remote  causes,  the  state  of 
disposition,  or  the  care  or  neglect  with  which  the  complaint  may 
be  treated.     But  be  the  period  longer  or  shorter,  it  is  almost 
always  found,  that  the  character  of  the  mucus  is  a  little  altered  ; 
becoming  thicker,  and  tinged  slightly  with  a  yellowish  hue,  be- 
fore the  inflammation  ceases  altogether,  or  proceeds  further  in 
the  course  of  the  mucous  membrane.     If  it  travel  upwards,  the 
membrane  lining  the  frontal  sinuses  becomes  implicated;  and 
then  is  experienced,  a  painful  fulness  in  the  frontal  bone,  which 
is  sometimes  severely  augmented,  by  every  attempt  to  dislodge 
the  frequent  accumulations  of  mucus  from  these  parts  by  the 
blowing  of  the  nose. 

1279.  When  the  change  just  spoken  of  in  the  quality  of  the 
mucus  (par.  1278,)  takes  place  in  the  nose,  we  find  the  patient 
experiences  a  relief  from  the  more  distressing  sensations  in  this 
part;  and  the  disease  may  soon  take  its  departure,  or  it  may  be 
protracted  by  the  inflammation  descending  into  the  trachea  and 
bronchia. 

1280.  Then  an  unpleasant  irritation  is  felt  in  the  larynx, 
almost  amounting,  in  some  instances,  to  an  itching — and  cough 
is  now  excited.     If  the  mucous  membrane  is  much  affected, 
we  may  have,  either  a  hoarseness,  or  a  loss  of  voice.     The 
former  may  be  the  forerunner  of  croup  ;  but  the  latter  seldom 
or  never. 

1281.  If  the  disease  enters  the  bronchia,  a  soreness  and  a 
sense  of  stiffness,  is  experienced  in  the  chest ;  especially  on  its 
anterior  portion,  along  the  internal  course  of  the  sternum.    This 
may  be  more  or  less  violent,  as  the  inflammation   may  have 
pervaded   the    bronchia   to   a    greater  or    less    extent.     This 
pain  is  sure  to  be  much  augmented  by  coughing ;  and  if  this  be 
strongly  provoked,  it  extends  over  the  whole  of  the  chest,  and 

49 


386  CATARRH. 

sometimes  appears  to  affect  even  the  diaphragm  itself,  if  we  may 
rely  upon  the  seat  of  pain,  for  this  assertion. 

1282.  This  extension  of  pain  through  the  thorax,  seems  to 
declare  the  extent  of  the  bronchial  inflammation,  and  is  for  a  time 
very  distressing  to  the  patient;  especially  as  a  sense  of  painful 
dryness  is  felt,  until  the  vessels  begin  to  relieve  themselves,  by 
pouring  out  mucus.  This  secretion  is  at  first  very  thin,  or  se- 
rous; and  occasionally  has  a  slight  saltish  taste  ;  and  in  appear- 
ance differs  but  little  from  the  saliva,  with  which  it  may  be 
mixed.  In  children,  this  mucus  is  sometimes  so  suddenly  and 
abundantly  secreted,  as  to  threaten  suffocation;  and  perhaps  this 
would  really  happen,  had  not  nature  made  a  provision  to  coun- 
teract this  tendency,  by  possessing  the  larynx  and  stomach  with 
an  important  sympathy  between  each  other,  to  supply  the  place 
of  expectoration.  Hence,  we  find  in  young  children,  that  an 
effort  to  vomit  is  almost  always  excited,  whenever  this  surplus 
mucus  is  forced  into  the  larynx;  which  effort  kindly  relieves 
this  part  from  its  embarrassment,  and  prevents  suffocation. 

1283.  In  the  adult,  this  risk  is  never  incurred  ;  as  voluntary 
expectoration  is  constantly  exercised,  whenever  the  sense  of  its 
necessity  is  excited,  by  a  peculiar  sensation  taking  place  in  the 
lungs,  or  in  the  course  of  the  trachea.     In  children,  the  appear- 
ance of  the  mucus  does  not  vary  so  much  as  in  the  adult;  in  the 
former  it  may  be  very  abundant;  but  it  almost  always  retains 
its  transparency,  to  a  greater  or  less  degree,  however  tenacious 
it  may  be  in  consistency.     While  in  the  adult,  this  substance  is 
sometimes  found  to  include  a  dense,  inspissated  phlegm,  of  a  pe- 
culiar whiteness,  or  even  a  true  pearl  colour  ;  and  this  is  some- 
times accompanied  with  a  dark,  fuliginous  matter,  or  even  by 
slight  streaks  of  blood.     And  after  a  while,  the  sputa  become 
tenacious,  yellow,  or  greenish. 

1284.  Early  morning,   generally  speaking,  is  the  period   at 
which  the  cough  is  the  most  troublesome;  it  is  sometimes  aug- 
mented after  meals,  especially  if  these  have  consisted  of  animal 
substances.     When  the  expectoration  is  very  abundant  and  fre- 
quent; and  particularly  if  much  effort  has  been  employed  to  dis- 
lodge the  mucus  from  the  bronchia,  a  sense  of  rawness  or  ten- 
derness is  felt,  indicating  the  denuded  condition  of  the  bronchial 
ramifications. 

1285.  In  general,  in  adults,  the  sanguineous  system  is  not  se- 
verely .affected   in  the  commencement  of  catarrh;  though  slight 
fever  may  be  observed  during  its  course;  but  this  is  more  par- 
ticularly obvious  in  children.  This  febrile  condition  is  most  evi- 
dent in  the  evening  ;  and  it  sometimes  terminates  like  a  genuine 
paroxysm  of  fever,  in  a  slight  perspiration  towards  morning, 
and  with  a  lateritious  deposit  in  the  urine. 


CATARRH.  387 

1286.  In  the  severer  forms  of  this  complaint,  fever,  during 
its  whole  course,  is  obviously  present;  a  difficulty  of  breathing 
rarely  attends  this  form  of  bronchial    disease,   unless  tempo- 
rarily, as  in  children  ;  and  then  only  when  the  secretion  of  mu- 
cus is  very  abundant.     If  it  accompany  catarrh  in  the  adult,  it 
is  only  under  its  severest  form,  or  where  there  exists  some  or- 
ganic lesion.     In  such  cases,  the  fever  may  be  severe ;  and  the 
disease  may  assume  a  menacing  appearance,  from  other  import- 
ant structures,  as  the  brain,  or  stomach,  being  made  to  partici- 
pate with  the  catarrhal  fever. 

1287.  This  complaint  is  caused  by  the  sudden  application  of 
cold  when  the  body  is  hot;  by  the  long-continued  exposure  to 
cold  and  moisture  when  the  body  is  not  heated;  by  the  sudden 
transition  from  a  cold,  to  a  heated  atmosphere ;  or  from  a  partial 
draught  of  air  upon  some  part  of  the  body,  but  especially  upon 
the  head.     But  one  of  its  most  fruitful  sources,  is  exposure  to 
cold,  while  the  skin  is  wet  or  moist  with  perspiration,  as  after 
dancing,  or  other  exercise.   With  children,  it  is  most  frequently 
produced  by  keeping.them  standing  in  a  cold  atmosphere,  as  at 
the  door  or  window;  by  being  suddenly  placed  there  soon  after 
they  have  risen  from  sleep;  or  by  being  kept  too  long  under  the 
operation  of  washing,  &c. 

1288.  Before  we  detail  the  mode  of  cure,  it  may  be  well  to 
consider  the  pathology  of  this  disease — this  may  be  the  more 
necessary,  as  much  popular  error  exists  on  the  subject  of  colds. 

1289.  Laennec  informs  us,  that  "  a  redness  more  or  less  mark- 
ed, and  at  most  a  slight  thickening  of  the  internal  membrane  of 
the  bronchia,  are  the  only  traces  which  this  disease  leaves  in  the 
affected  organs ;  if  we  except  a  certain  quantity  of  phlegm  in  the 
bronchia,  resembling  that  expectorated  by  the  patient.    The  red- 
ness and  swelling  very  rarely  occupy  the  whole  bronchial  mem- 
brane, even  of  one  lung.     When  the  contrary  is  the  case,  the 
disease  is  very  severe,  and  accompanied  by  a  violent  fever.  Most 
commonly  there  is  congestion  only  in  certain  parts  of  the  mem- 
brane in  one  or  both  lungs,  even  when  there  is  much  fever  and 
expectoration.     The  portions  which  are  red  and  swollen,  are 
usually  more  consistent  than  natural ;  sometimes  they  are  some- 
what softer,  particularly  in  the  catarrhs  which  accompany  severe 
fevers;  and  occasionally,  the  degree  of  the  softening  is  equal  to 
that  which  occurs  in  the  mucous  membrane  of  the  stomach  and 
intestines,  in  certain  cases.     The  extent  and   intensity  of  the 
redness  are  not  always  in  proportion  to  the  violence  of  the  in- 
flammation ;  the  quantity  of  expectoration,  or  the  acuteness  of 
the  case.     Thus,  in  the  catarrh,  whether  latent  or  not,  which 
complicates  fevers,  we  find  the  membrane  swollen,  and  of  a  livid 
red  over  almost  its  whole  extent;  and  even  softened,  here  and 
there ;  while  in  the  idiopathic  disease,  even  when  very  acute,  it 


388  CATARRH. 

exhibits  marks  of  inflammation  in  certain  points  only."  Laen- 
nec,  however,  observes,  "that  the  redness  and  softening  of  the 
bronchial  membrane  are  always  the  more  marked  according  as 
the  examination  is  remote  from  the  period  of  death,  and  the  de- 
composition of  the  body  more  advanced."*  In  children,  and 
especially  in  very  young  children,  the  disease  appears  to  be  al- 
most altogether  confined  to  the  lining  membrane  of  the  nose, 
which  shows  itself  after  death  by  marks  of  inflammation  of  the 
mucous  membrane  lining  the  nostrils,  and  extending  towards  the 
larynx — the  membrane  has  also  been  found  softened.  And  it 
is  said  that  this  tissue  sometimes  furnishes  a  membrane  similar 
to  that  produced  in  the  trachea  by  croup — this  we  have  never 
seen. 

1290.  Notwithstanding  that  catarrh  obviously  consists  of  an 
inflammation  of  the  mucous  membrane  of  the  bronchia,  Laennec 
declares,  "that  bleeding  is  rarely  useful  in  it,  except  in  very  ro- 
bust constitutions,  or  where  the  symptoms  are  so  severe  as  to 
threaten  peripneumony,  or  where  there  is  blood  in  the  expecto- 
ration." p.  69.     How  far  this  may  be  true  in  the  comparatively 
mild  climate  of  France,  we  cannot  pretend  to  determine;  but  in 
this  and  in  climates  similar  to  our  own,  it  would  be  a  dangerous 
doctrine  to  inculcate,  especially  when  the  disease  attacks  chil- 
dren.     It  is  true,  we  may  give  so  extensive  a  latitude  to  his  ex- 
ceptions, as  to  make  them  meet  all  the  necessary  exigencies  of 
the  disease;  but  it  is  obviously  not  his  intention  that  this  should 
be  done.     For  he  very  emphatically  declares,  that  "  this  mea- 
sure, with  the  exceptions  just  named,  has  always  been  rejected 
by  good  practitioners,  as  rendering  the  disease  of  longer  dura- 
tion,   as   diminishing  and  sometimes  checking  the  expectora- 
tion." Ib. 

1291.  The  remarks  of  Laennec  we  believe,  cannot  apply  with 
much  truth  to  the  catarrh  of  this  country;  for  here,  we  are  very 
•often  under  the  necessity  of  employing  the  lancet,  if  the  inflam- 
mation has  taken  possession  of  the  bronchial  surface.     But  if  it 
confine  itself  to  the   Schneiderian  membrane  or  to  the  frontal 
sinuses,  bleeding  we  grant,  will  rarely  be  necessary;  but  if  it 
invade  the  trachea  and  lungs,  the  cough  will  very  often  require 
the  loss  of  blood  for  its  relief;  especially  if  this  be  attended  by 
pain  and  soreness  in  the  chest,  and  by  a  riving  pain  in  the  head. 
Indeed  the  latter  symptom  alone,  has  frequently  led  us  to  the 
employment  of  the  lancet  for  its  relief;  and  so  far  we  think,  it 
has  always  been  useful. 

1292.  We  have  never  witnessed  the  ill  effects  of  bleeding  men- 
tioned by  Laennec;  namely, its  having  "rendered  the  disease  of 
longer  duration,  and  as  diminishing  and  sometimes  checking 

•  Diseases  of  the  Chest,  Forbes's  Trans,  p.  62. 


CATARRH.  389 

expectoration."  On  the  contrary,  we  have  very  often  been  un- 
der the  necessity  of  abstracting  blood,  with  a  view  of  promoting 
the  bronchial  secretion ;  and  further,  we  can  very  confidently 
declare,  we  have  rarely  failed  to  have  our  intention  fulfilled. 

1293.  We  are  every  way  confident  that  in  children  did  we 
not  sometimes  employ  bleeding  in  this  disease,  we  should  with- 
hold one  of  the  most  efficient  remedies  for  its  cure,  if  we  did  not 
pretty  suddenly  convey  them   to  an  unnecessarily  early  tomb ; 
or  the  disease  would  spin  itself  out  to  a  great  length,  and  even- 
tually perhaps  terminate  in  incurable  effusions  within  the  bron- 
chial ramifications,  or  leave  chronic  congestion  within  the  sub- 
stance of  the  lungs. 

1294.  We  therefore  never  fail  to  recommend  the  abstraction 
of  blood,  when  fever  and  pain  attend,  or  if  dyspnoea  be  present. 
We  abstract  blood  from   either  the  arm,  or  from  between  the 
shoulders  by  leeches,  when  children  are  the  subjects — from  the 
arm  at  first,  preferably,  if  there  be  much  heat  of  skin,  oppression, 
and  crying 'after  each  spell  of  coughing.     Children  are  more 
liable,  as  we  have  already  observed,  to  a  more  exalted  degree  of 
bronchial  inflammation  than  adults;  but  as  many  find  it  difficult 
to  ascertain  its  presence  in  catarrh,  and  withhold  the  lancet  from 
this  cause,  it  may  be  well  to  remark,  that  the  following  simple 
signs,  have  never  failed  to  point  out  to  us  this  condition  of  the 
mucous  membrane  of  the  bronchia,  if  it  existed. 

1295.  First.  The  child  is  disposed  to  lie  on  its  back,  with  its 
head  thrown  backward,  even  lower  than  its  chest;  and  when  an 
attempt  is  made  to  raise  it,  it  resists  the  change  as  much  as  it  can, 
by  stiffening  its  neck,  and  suffering  itself  to  be  elevated  in  this 
condition,  by  the  hand  being  placed  upon  the  hind-head. 

1296.  Second.   When  this  attempt  is  made,  the  child  shows 
that  the  effort  is  attended  by  pain,  by  its  complaining  or  crying 
at  the  moment. 

1297.  Third.  The  child  is  sure  to  cry  after  each  spell  of 
coughing,  with  more  or  less  violence;  and  if  it  be  old  enough, 
it  may  be  observed  to  make  efforts  to  prevent  coughing  from 
taking  place. 

1298.  When  these  signs  combine,  or  even  when  they  exist 
singly,  we  never  fail  to  abstract  blood,  and  this  almost,  always 
with  marked  advantage;  nor  do  we  stop  here,  if  these  symptoms 
continue;  for  we  bleed  or  leech  again  and  again  if  necessary. 
Laennec's  opinion  of  leeching,  however,  is  not  more  favourable 
than  it  is  of  bleeding  from  the  general  system;  for  he  says,  that 
"leeching  has  the  advantages  and  disadvantages  of  venesection, 
only  in  a  less  degree."  Ib. 

1299.  He  however  says,  that  "  cupping  is  in  general  more 
useful.  By  using  many  glasses,  and  yet  taking  away  only  a  small 


390  CATARRH. 

quantity  of  blood  at  one  time,  and  more  particularly  by  keeping 
the  glasses  applied  for  a  considerable  time,  so  that  the  tumefac- 
tion produced  by  them  does  not  too  speedily  subside,  we  fre- 
quently obtain,  in  the  severer  cases,  marked  relief  of  the  op- 
pression and  other  symptoms."  p.  69.  He  could  not  well  have 
demonstrated  the  necessity  of  losing  blood  better  than  by  this 
last  direction — for  though  he  directs  but  a  small  quantity  of  blood 
to  be  taken  at  one  time,  he  nevertheless  directs  the  application 
of  "  many  cups,"  and  attaches  a  value  to  them  in  proportion  to 
the  continuance  of  "  the  tumefaction  produced  by  them." 

1300.  Now,  we  would  ask,  on  what  does  the  continuance  of 
the  "  tumefaction"  depend?     Certainly  upon   nothing,  but  the 
degree  of  extravasation  that  the  cups  produce;  and  the  quantity 
of  blood  that  is  poured  into  the  cellular  substance,  is  as  much 
and  as  certainly  withdrawn  from  the  circulating  mass,  as  if  it  had 
been  drawn  by  opening  a  vein;  therefore  the  system  is  deprived 
of  so  much  blood.  We  however  admit  that  the  effects  are  some- 
times more  important  and  less  debilitating  than  if  so  much  had 
been  abstracted  suddenly  by  opening  a  vein.     This  arises  from 
the  very  slow  manner  in  which  the  blood  is  drawn  from  the  cir- 
culation; and  also  by  the  capillaries  furnishing  a  certain  propor- 
tion of  it,  and  which  quantity  might  almost  be  said  to  be  already 
out  of  the  common  circulation,  and  would  not  be  so  certainly 
missed  by  the  heart  and  larger  blood-vessels. 

1301.  Leeches  produce  a  very  extraordinary  effect  upon  the 
system  ;  one  altogether  different  from  that  produced  by  the  open- 
ing of  a  vein.     For  the  faintness  which  takes  place  after  leech- 
ing, bears  very  little  analogy  to  that  which  follows  venesection; 
for  the  quantity  of  blood  abstracted  by  them,  will  by  no  means 
always  account  for  the  peculiar  state  of  exhaustion  the  patient  ex- 
hibits from  their  application.     The  state  alluded  to  seems  to  be 
produced  by  some  unknown  action  upon  the  nervous,  rather  than 
upon  any  loss  of  balance  in  the  sanguiferous  system.   It  has  been 
attempted  to  be  accounted  for,  by  calling  in  the  aid  of  the  ima- 
gination, or  the  horror  which  some  feel  at  the  sight  of  the  ani- 
mal itself — but  this  can  only  obtain  where  such  aversion  exists; 
but  it  will  not  account  for  this  effect,  when  this  power  is  not  ex- 
ercised, as  in  children,  &c.     Be  this  as  it  may,  as  regards  the 
immediate  cause  of  this  state  of  faintness,  the  effects  are  some- 
times highly  valuable;  for  when  it  takes  place,  it  saves  almost 
always,  a  considerable  expenditure  of  blood  ;  for  we  have  con- 
stantly remarked,  that  arterial  action   has  been  more  certainly 
and  permanently  abated,  than  when  a  state  of  exhaustion  has  been 
produced  by  the  direct  abstraction  of  blood  by  venesection ;  for 
after  this,  a  reaction  almost  always  follows,  which  is  not  so  cer- 
tainly the  case  with  leeching. 


CATARRH.  391 

1302.  It  is  true  that  leeches  may  produce  faintness,  from  the 
over-quantity  of  blood,  they  may  abstract;  when  this  happens, 
the  faintness  is  precisely  like  that  produced  by  venesection;  but 
it  does  not  resemble  the  state  in  question.     Cupping,  which  cer- 
tainly bears  a  strong  resemblance  to  leeching,  in  its  mode  of  ac- 
cumulating and  abstracting  blood,  yet  it  never,  so  far  as  we  have 
seen,  produces  an  effect  similar  to  that  induced  by  leeches. 

1303.  We  are  therefore  very  partial  to  their  employment, 
especially  in  children  ;  and  particularly  after  the  force  of  the  arte- 
rial system  has  been  abated  in  urgent  cases,  by  a  bleeding  from 
the  arm.  We  are  persuaded,  that  no  remedy  meets  the  exigencies 
of  the  disease  so  well  as  leeches  where  a  further  reduction  of  the 
system  by  the  loss  of  blood  is  required.   And  we  are  in  the  con- 
stant habit  of  using  these  little  animals,  whenever  there  is  fever 
with  a  confined   breathing,  together  with  the  marks,  which  we 
have  just  declared,  betray  a  lurking  inflammation  in  some  part 
of  the  pulmonary  system  ;  for  it  may  be  remarked,  that  an  exalt- 
ed, acute  mucous  catarrh  may  be  complicated  with  inflammation 
of  some  other  portion  of  the  lungs,  than  the  bronchia.    Leeches 
in  such  cases  should  be  applied  between  the  superior  portions  of 
the  scapulae  or  shoulder  blades. 

1304.  The  bowels  should  be  well  opened;  first  by  calomel, 
followed  by  castor  oil  or  magnesia;  that  is,  a  few  grains,  say 
eight  or  ten,  for  an  adult,  or  three  or  four  for  a  child,  should 
be  given  at  once;  and  if  it  do  not  operate  in  three  or  four  hours, 
it  must  be  followed  by  either  of  the  medicines  just  named,  in  a 
suitable  quantity  so  as  to  secure  three  or  four  evacuations. 

1305.  With  children,  the  calomel  oftentimes  answers  an  ad- 
mirable purpose,  by  exciting  the  stomach  to  vomiting,  whenever 
there  is  any  thing  crude  or  offensive  in  it,  and  it  very  rarely 
fails  afterwards  to  affect  the  bowels.     The  belly  should  be  kept 
open  during  the  course  of  the  acute  stage  of  the  disease;  but  it 
is  seldom  necessary  to  purge  briskly.     Indeed  this  is  sometimes 
injurious,  especially  when  there  is  a  tendency  to  diarrhoea,  as 
sometimes  happens  when  the  first  stage  has  been  neglected  or 
improperly  treated,  as  but  two  frequently  happens,  in  conformity 
to  an  old,  but  ill-understood  adage  ;  namely,   "feed  a  cold,  but 
starve  a  fever."    Unfortunately,  this  proverb  is  obeyed  literally 
in  too  many  instances;  and  this  sometimes  to  the  destruction  of 
the  patient.     The  true  interpretation  of  this  "  old  saw,"  is,  that 
you  are  to  starve  a  cold,  because  there  is  always  more  or  less 
fever  with  it. 

1306.  Indeed,  Laennec  himself  may  be  justly  charged  with 
having  perpetuated  an  indifference  to  a  "  cold,"  by  the  employ- 
ment of  a  similar  saying;    "a  cold  well  nursed  lasts  forty  days, 
and  a  cold  not  nursed  lusts  six  weeks;  (p.  70,)  for  it  directly  im- 


392  CATARRH. 

plies  that  it  will  run  a  certain  course  in  spite  of  opposition;  and 
that  it  will  last  no  longer,  if  it  be  indulged  in  its  course.  This 
doctrine  is  particularly  dangerous,  when  sanctioned  by  such  high 
authority,  especially  as  the  statement  has  no  foundation  in  fact; 
at  least,  not  in  this  country.  For  we  are  as  certain  as  we  can  be 
of  any  fact,  not  mathematically  demonstrable,  that  a  catarrh  can 
very  often  be  cut  short,  if  it  be  taken  at  a  certain  period ;  and 
that  its  duration  and  force  can  be  very  much  diminished  by  a 
proper  mode  of  treatment;  of  this  we  shall  speak  presently. 

1307.  In  the  treatment  of  catarrh,  we  have  directed  the  loss 
of  blood  and  moderate  purging ;  in  addition  to  these,  when  the 
case  has  required  them,  we  direct  occasional  puking  with  chil- 
dren, and  the  pretty  steady  use  of  expectorants.     Children  are 
liable  in  this  complaint  to  oppressive  accumulations  of  phlegm  ; 
owing  very  often  to  the  entire  want  of  the  voluntary  power  to 
expectorate.    It  therefore  becomes  important,  that  the  bronchia 
should  be  relieved  from  this  surcharge  of  mucus  ;  and  in  most 
instances,  this  can  only  be  done  by  exciting  the  action  of  the 
stomach. 

1308.  It  sometimes  happens,  however,  in  the  more  acute  stage 
of  this  complaint,  that  the  secretion  of  mucus  is  either  not  suffi- 
ciently abundant,  or  that  it  is  too  tenacious  to  be  readily  deliver- 
ed from  the  bronchial  ramifications  ;  in  each  of  these  cases,  ex- 
pectorants are  highly  valuable  ;  and  should  always  be  had  re- 
course to,  after  bleeding  and  purging,  if  the  case  have  required 
these  latter  remedies  ;  or  immediately,  if  the  state  of  the  system 
should  not  require  them. 

1309.  For  these  purposes,  as  well  as  to  excite  occasional  vo- 
miting, we  know  of  nothing  equal  to  the  compound  syrup  of 
squills,  or  as  it  is  more  familiarly  called,  Coxe's  hive  syrup.* 
This  medicine  can  be  employed  so  as  to  satisfy  each  of  these  in- 
tentions.    Thus,  to  a  child  that  it  may  be  proper  to  puke,  the 
appropriate  dose,  must  be  repeated  every  fifteen  or  twenty  mi- 
nutes until  the  stomach  revolts.    When  the  secretion  is  not  suffi- 
ciently abundant  or  is  too  tenacious,  the  proper  dose  may  be  re- 
peated every  two  hours.     A  solution  of  the  tartrite  of  antimony 
is  also  a  valuable  expectorant,  and  febrifuge  with  children  ;  the 
adult  will  rarely  require  either  the  syrup  of  squills,  or  the  pre- 
paration of  antimony.   The  dose  of  the  tartrite  of  antimony  must 
be  minute  ;  the  twentieth  of  a  grain  every  two  hours,  will  be 
sufficient  for  children  from  a  year  to  two  years  old ;  a  thirtieth, 
for  children  from  six  months  to  a  year;  a  sixteenth,  for  children 
from  two  years  to  three  or  even  four  years  old  ;  unless  you  wish 
to  excite  vomiting.   In  this  case  it  may  have  double  the  strength 

*  See  Chapter  on  Hooping  Cough,  for  the  composition  of  this  article. 


CATARRH.  393 

specified  above.  Either  of  these  articles  becomes  highly  im- 
portant, if  the  cough  be  very  troublesome.  For  we  cannot  give 
any  preparation  of  opium  in  the  commencement  of  catarrh,  if  the 
symptoms  be  at  all  urgent,  though  it  becomes  highly  important 
in  its  decline,  or  when  it  is  in  its  forming  state.  It  may  how- 
ever be  proper  to  observe,  that  we  would  prefer  the  solution  of 
tartar  emetic  to  the  hive  syrup,  if  the  fever  be  high  in  the  com- 
mencement, or  remained  unsubdued. 

1310.  Much  mischief  is  done  by  the  indiscriminate  exhibi- 
tion of  opium,  in  some  form  or  other,  in  this  complaint ;  be- 
cause cough  is  present,  it  is  considered  as  a  matter  of  course 
that  laudanum  should  be  given ;  but  opium  in  any  shape  what- 
ever, must  not  be  used  when  the  pulse  is  active,  the  skin  hot, 
the  expectoration  sparing  or  very  thin,  or  the  oppression  consi- 
derable.    It  can  only  be  given  with  advantage  when  the  con- 
trary of  all  these  obtain ;  it  then  is  not  only  safe,  but  absolutely 
proper.     The  best  forms  for  its  exhibition,  is  that  of  the  brown, 
or  the  spermaceti  mixture.* 

1311.  During  the  whole  treatment  of  acute  catarrh,  the  strict- 
est antiphlogistic  regimen  should  be  observed ;  we  have  else- 
where, (pars.  214,  215,  216,)  explained  our  meaning  of  this 
term.     The  most  plentiful  dilution  should  be  indulged  in  ;  the 
air  of  the  room  should  never  exceed  60°,  if  possible  to  prevent  it. 
All  sudden  transitions  of  temperature  should  be  avoided  with  much 
care ;  and  the  body  should  not  be  overheated  by  clothes,  nor 
the  temperature  of  the  skin  be  too  much  reduced  for  want  of  a 
sufficient  quantity  of  them.     By  the  first,  the  skin  is  stimulated 

*  The  brown  and  spermaceti  mixtures  are  made  as  follows: — 


R.  Elix.  paregor. 

Vin.  Autim.  ...    gss. 

Pulv.  g.  Arab.  -        -        ^iij. 

Succ.  glycrrh.  -                     giij. 

Aq.  fervent.  •        .        Ivj. 
M. 


Take  Paregoric  elixir,    -  1  ounce. 
Antimonial  wine,   -  J  ounce. 
Powdered  gum  Ara- 
bic   •        -        -  3  drachms. 
Liquorice  extract,  3  drachms. 
Hot  water,    -        -  6  ounces. 
M. 

An  adult  may  take  a  table-spoonful  every  three  or  four  hours  Until  cough  is  re- 
lieved. A  child  of  six  months  to  a  year,  a  common-sized  tea-spoonful;  above 
this  age,  from  a  large  tea-spoonful  to  a  dessert-spoonful. 


Or  the  spermaceti  mixture: — 
R.    Sperm  ceti,    ... 
Vitel  ovi,    - 
Pulv.  g.  Arab. 
Elix.  paregor.    - 
Vin.  antim.     ... 
Sacch.  alb.         ... 
Aq.  font.         ... 
M. 


This  is  to  be  used  as  directed  above  for  the  Brown  Mixture. 

50 


Take  Spermaceti,       -  2  drachms. 
Yelk  of  egg,       -  1 
Powdered  gum  Ara- 
bic,       -       -  2  drachms. 
Paregoric  elixir,     -  1  ounce. 
Antimonial  wine,   -  i  ounce. 
White  sugar,         -  3  drachms. 
Mix. 


394  CATARRH. 

beyond  the  sweating  point ;  and  by  the  second,  it  is  prevented 
from  rising  to  it. 

1312.  Blisters  are  sometimes  highly  useful   in  catarrh;  but 
they  are  very  frequently  much  abused,  by  applying  them  when 
they  may  not  be  absolutely  required,  or  at  too  early  a  period  of 
the  disease.    When  the  latter  happens,  they  are  sure  to  augment 
fever,  and  thus  increase  the  congestion  of  the  bronchia.    But 
when  properly  resorted  to,  they  act  as  very  important  revulsives. 
We  think  the  best  place  for  their  application  is  between  the 
shoulders  ;  the  same  spot  to  which  we  have  directed  the  leeches 
to  be  applied.     They  are  rarely  proper  to  the  thorax  in  simple 
catarrh,  however  acute ;  but  when  complicated  with  inflamma- 
tion in  some  other  structure  of  the  lungs  besides  the  bronchia, 
they  may  render  very  important   aid  to  the  other  remedies. 
Much  care,  however,  should  be  taken,  that  the  pulse,  and  heat  of 
the  skin,  be  sufficiently  reduced,  to  bear  their  stimulation,  be- 
fore they  are  made  use  of. 

1313.  It  would  seem,  that  a  cold  lasts  much  longer  in  France 
than  in  this  country,  if  the  proverb  quoted  from  Laennec  have 
any  foundation;  but  not  necessarily  so  we  imagine,  unless  the 
mode  of  treatment  be  very  faulty  indeed.    In  this  country,  even 
when  the  severity  of  a  long  winter  has  to  be  contended  against, 
a  catarrh  with  proper  management  will   almost  always  yield  in 
two  weeks,   and  sometimes  even  sooner.     We  are,  therefore, 
no  ways  disposed  to  yield  to  the  opinion  of  Laennec  upon  this 
point;  especially  as  we  have  abundant  experience  even  in  our 
own  person  to  enable  us  to  declare,  that  this  affection  can,  not 
only  be  much  abridged  in  duration,  but,   in  many  instances, 
cut  short. 

1314.  In  order,  however,  to  accomplish  either  of  these  very 
desirable  ends,  this  disease  must  be  attacked  either  in  its  form- 
ing state,  or  very  soon  after  it  is  formed. 

1315.  If  attended  to  in  its  forming  state,  it  can  very  frequently 
be  put  a  stop  to,  by  bathing  the  feet  for  a  few  minutes  in  warm 
salt  water  at  bed  time,  and  taking  twenty-five  drops  of  laudanum 
and  as  much  sweet  spirit  of  nitre,  (spiritus  aetheris  nitrosi,)  in  a 
little  sugar  and  water,  drinking  after  it  a  glass  of  hot  lemonade. 
This  simple  plan  has  very  frequently  prevented  a  "cold"  from 
fixing  itself  upon  the  chest.   During,  however,  any  appearance  of 
catarrh,  the  diet  should  be  strictly  antiphlogistic,  until  it  ceases 
to  trouble. 

1316.  Laennec  proposes  a  plan  for  the  same  purpose,  but 
which  we  cannot  feel  safe  to  recommend,  however  successful  it 
may  occasionally  be.     He  says,   "  my  plan  is  to  give  to  the  pa- 
tient at  bed  time,  an  ounce  or  an  ounce  and  a  half  of  good  brandy 
in  double  the  quantity  of  an  infusion  of  violets,  made  very  hot 


CATARRH.  395 

and  sweetened  with  syrup  of  marsh  mallows.  This  dose  is 
usually  followed  by  a  copious  perspiration  towards  morning;  but 
frequently  the  disorder  is  cured  the  same  day  without  any  per- 
spiration. If  this  is  not  the  case,  the  same  plan  is  followed  seve- 
ral nights  successively."  p.  70. 

1317.  Dr.  Forbes,  in  a  note  to  this  plan  of  Laennec,  makes 
the  following  judicious  and  highly  valuable  practical  remarks. 
*'A  catarrh,  or  common  cold,  as  it  is  called,  is  of  such  every 
day  occurrence,  and  in  general  of  such  moderate  severity,  as  sel- 
dom to  come  within  the  pale  of  formal  medical  treatment.   The 
very  tolerable  amount  of  its  evils,  and  the  confident  expectation 
of  being  speedily  freed  from  these  by  the  simple  process  of  nature, 
no  doubt  render  it  frequently  of  long  duration,  when  it  might  be 
removed  very  speedily,  and  occasion  many  remedial  measures  of 
well  known  efficacy  to  fall  into  neglect.  Of  this  kind  is  the  inhala- 
tion of  the  steam  of  warm  water,  conjoined  with  the  internal  use 
of  diaphoretics  and  the  application  of  steam  to  the  surface  of  the 
body,  formerly  recommended  by  Mr.  Mudge,  and  described  in 
his  excellent  Essay  entitled,  "A  Radical  and  Expeditious  Cure 
for  Recent  Catarrhous  Cough."  Whoever  will  be  at  the  expense 
of  procuring  his  "Inhaler,"  and  will  take  the  trouble  to  use  his 
process  at  the  exact  period  of  the  disease,  (i.  e.  at  the  very  onset,) 
and  precisely  in  the  manner  recommended  by  him,  will  I  do  not 
doubt,  find  therein  a  remedy  at  least  as  efficacious  and  speedy, 
and  certainly  more  safe,  than  the  spirituous  treatment  of  our 
author.     But  perhaps  after  all,  for  those  who  have  leisure  for 
such  luxurious  medication,  and  who  do  not  consider  such  3.  re- 
strictive mode  of  cure,  as  worse  than  the  disease,  the  safest  and 
surest  remedy  is  to  lie  in  bed  and  live   on  slops  for  a  day  or 
two."  p.  71. 

1318.  From  the  common  belief,  that  a  cold  will  run  its  course 
do  as  you  may;  and  its*not  incapacitating  such  as  may  be  attacked 
with  it  from  attending  to  their  usual  occupations;  but  above  all, 
from  the  aversion  which  very  many  have  to  reduce  the  quantity, 
or  to  change  the  quality  of  their  food,  very  few  are  tempted,  to 
abridge  the  career  of  a  cold,  however  certainly  this  may  be  in 
their  power.    Yet  we  feel  it  a  duty,  as  well  as  its  being  a  part  of 
our  plan,  to  give  our  opinion  upon  this  subject. 

1319.  When  catarrh  has  acquired  so  much  force,  that  the  plan 
above  suggested  to  arrest  its  progress,  would  be  either  unavailing 
or  injurious,  still  much  can  be  done  to  abate  its  severity,  or  to 
shorten  its  duration.  This  must  be  attempted  by  the  observance 
of  a  strict  antiphlogistic  regimen;  guarding  against  exposures  of 
every  kind,  and   by  drinking  very  freely  of  either  of  the  fol- 
lowing demulcent  and  diluent  drinks;  flaxseed,  or  slippery  elm 
bark,  or  bran  tea,  barley  water,  rice  water,  molasses  and  water, 


396  CYNANCHE    TONSILLARIS. 

or  even  toast  water.  This  plan  should  be  persevered  in,  until 
all  arterial  irritation  cease,  which  will  happen,  when  the  disease 
is  of  a  mild  grade,  in  about  five  or  six  days;  after  this  period 
the  patient  may  gradually  return  to  his  ordinary  diet.  But  if  he 
be  in  the  habit  of  taking  other  drinks  than  water,  he  should  ab- 
stain from  every  species  of  liquor  until  cough  has  entirely  ceased. 
If  this  do  not  succeed,  the  disease  will  then  be  of  a  more  acute 
character,  and  must  be  treated  as  already  directed  for  the  active 
stage  of  "acute  mucous  catarrh." 

SECT.  II. — CYNANCHE  TONSILLARIS. 

1320.  This  disease  comes  on  with  a  huskiness,  followed  by 
pain  and  inflammation  of  the  tonsils  and  back  part  of  the  throat, 
attended  with  some  difficulty  of  deglutition,  and  sometimes  with 
fever.  In  a  short  time  these  symptoms  are  increased;  and  from 
the  swelling  of  one,  or  both  tonsils,  there  is  a  great  inability  to 
swallow.     If  the  throat  be  examined  at  this  time,  we  find  the 
uvula,  the  pharynx,  and  the  neighbouring  parts,  extremely  red, 
and  excessively  tender.  In  some  instances,  and  especially  where 
the  individual  has  had  many  preceding  attacks,  it  shows  itself  as 
a  mere  local  affection,  without  fever,  or  any  general  constitutional 
disturbance. 

1321.  In  this  form  of  the  disease,  we  have  phlegmonous  in- 
flammation, which  terminates,  usually,  either  by  resolution  or 
suppuration,  and  sometimes  by  induration  of  the  glands.     But 
in  other  cases,  it  puts  on  the  appearance  of  erysipelas;  and  here, 
instead  of  red  vivid  inflammation,  with  much  swelling,  the  aspect 
is  dark,  or  purple ;  with  superficial  vesicles,  or  ulcers,  of  a  white 
or  gray  colour,  resembling  ordinary  aphthae. 

1322.  Commonly,  no  species  of  this  disease  is  dangerous, 
whatever  may  be  the  degree  of  the  immediate  suffering ;  and 
only  becomes  so,  when  the  inflammation  extends  to  more  im- 
portant structures,  as  the  larynx,  and  trachea. 

1323.  The  symptoms,  however,  sometimes  run  very  high; 
and  great  suffering  is  endured ;  and  the  tonsils  become  so  en- 
larged and  engorged,  as  to  nearly  fill  up  the  posterior  fauces. 

1324.  Deglutition  is  now  extremely  difficult,  and  sometimes 
altogether  impossible,  without  a  repetition  of  the  greatest,  and 
most  painful  efforts.  Under  such  circumstances  it  is  not  unusual 
for  cough  to  be  excited,  and  drive  whatever  is  attempted  to  be 
swallowed  through  the  nostrils.     The  faucial  extremities  of  the 
Eustachian  tubes,  are  very  apt  to  be  involved  in  this  inflamma- 
tion ;  when  this  is  the  case,  each  attempt  to  swallow  is  followed 
by  an  acute  darting  pain  through  the  course  of  the  tubes,  which 
seems  to  terminate  in  the  external  ear. 


CYNANCHE    TONSILLARIS.  397 

1325.  One  of  the  most  troublesome  symptoms  against  which 
the  patient  has  to  contend,  is  the  free  secretion  of  a  very  tena- 
cious mucus ;  this  quickly  accumulates  in  sufficient  quantity  to 
force  the  patient  to  swallow  it;  in  which  attempt,  the  pain  be- 
comes so  excessive  as  to  produce  a  convulsive  action  of  almost 
every  muscle  in  the  body.     This  secretion  is  particularly  trou- 
blesome when  the  patient  attempts  to  sleep — so  much  so  indeed 
sometimes,  as  almost  to  preclude  the  possibility.  To  obviate  this 
as  much  as  possible,  the  patient  should  make  his  mouth  so  de- 
pending, that  it  may  flow  out  before  it  accumulates  in  such  quan- 
tities as  will  oblige  him  to  swallow.    The  whole  of  the  muscles 
of  the  fauces  and  tongue,  partake  so  much  of  the  inflammation, 
that  it  is  impossible  sometimes  to  protrude  the  latter ;  the  effort 
is  always  attended  with  pain. 

1326.  The  tongue  is  quickly  incrusted  with  a  thick,  very  white 
coat.  The  fever  which  sometimes  accompanies  the  cynanche  ton- 
sillaris  is  sometimes  very  high;  at  others  very  much  less  than  we 
should  suppose  would  attend  an  inflammation  of  such  extent  and 
apparent  violence.  With  those  who  are  liable  to  attacks  of  sore 
throat,  the  fever  for  the  most  part  is  moderate;  indeed  in  some 
instances  it  seems  to  decline  in  proportion  to  the  frequency  of 
the  occurrence,  as  if  the  system  had  lost  some  portion  of  its 
sympathizing  powers.     We  however  know  of  but  few  diseases 
which  leaves  so  much  debility  in  the  same  time  behind  it.  This 
may  perhaps  in  part  be  accounted  for,  from  the  entire  impossi- 
bility there  is  sometimes,  of  taking  down  nourishment. 

1327.  This  disease  is  sometimes  very  obstinate ;  the  inflam- 
mation notadvancingto  suppuration  nor  receding  by  resolution — 
this  is  especially  the  case  with  those  who  may  have  cynanche  to 
supervene  upon  enlarged  tonsils;  or  in  those,  who  have  the  lym- 
phatic temperament  strongly  marked. 

1328.  Cynanche  tonsillaris  is  almost  exclusively  produced  by 
exposure  to  cold.  There  are  many  persons  peculiarly  liable  to  it; 
and  a  predisposition  seems  to  be  especially  given,  by  former  at- 
tacks ;  and  hence  great  caution  is  required  to  avoid  the  exciting 
cause. 

1329.  The  practice  of  washing  the  throatevery  morning  with 
cold  water,  is  said  to  be  an  excellent  preventive;  and  we  know 
that  much  advantage  has  been  derived  from  gargling  the  throat 
every  morning  and  evening  with  a  solution  of  alum,  for  the  same 
purpose. 

1330.  The  treatment  of  this  disease  divides  itself  into  that 
which  is  proper  in  its  forming  state ;  and  into  that  proper  for  the 
subsequent  stages. 

1331.  If  we  are  called  very  early,  and  before  diseased  action 


398  CYNANCHE    TONSILLARIS. 

is  completely  established,  we  may  frequently  check  the  attack, 
by  a  stimulating  gargle;  such  as  an  infusion  of  Cayenne  pepper;* 
and  by  rubefacients,  such  as  the  spirit  of  turpentine,  or  mustard 
and  vinegar  applied  to  the  external  surface  of  the  throat,  until 
the  skin  becomes  inflamed;  or  even  by  warmth,  when  the  attack 
is  very  recent  and  mild,  as  a  piece  of  flannel  or  worsted  stock- 
ing, tied  around  the  neck.  But  should  these  fail,  we  must  change 
the  practice,  and  endeavour  to  reduce  the  inflammation  by  eva- 
cuations. An  emetic  is  here  exceedingly  efficacious;  generally 
resolving  the  swelling,  and  suppressing  the  fever,  if  it  exist;  this 
should  be  succeeded  by  a  mercurial  purge,  to  be  worked  off  by  a 
saline  laxative. 

1332.  If  necessary,  we  must  next  resort  to  blood-letting,  and 
especially  leeching  the  throat;  but  the  state  of  the  pulse  must 
always  govern  the  use  of  these  remedies;  especially,  the  lancet; 
but  leeches  may  be  used  with  advantage,  when  the  pulse  may  not 
require  bleeding  from  the  arm.     In  many  cases  it  is  not  at  all 
demanded;  particularly  as  it  is   rarely  productive  of  as  much 
utility,  as  might  be  expected.     Yet,  where  there  is  great  vascu- 
lar action  it  must  be  employed,  and  repeated  according  to  the 
emergency.    The  topical  bleeding,  by  cups,  or  leeches,  is  gene- 
rally more  effectual ;  and  especially,  where  the  affection  is  local, 
or  the  system  somewhat  reduced.     In  violent  cases,  or  even 
in  cases  threatening  to  be  violent,  blisters  should  be  employ- 
ed; and  this  as  early  after  the  leeching  and  other  depletion  as 
possible. 

1333.  Gargles,  in  this  state  of  the  disease,  are  always  detri- 
mental; as  they  aggravate  the  inflammation,  by  the  violent  and 
inverted  action  which  they  induce.     As  a  palliative,  a  mixture 
of  equal  parts  of  nitre  and  loaf  sugar  finely  powdered,  occasion- 
ally put  on  the  tongue,  and  as  it  melts,  allowed  to  trickle  over 
the  inflamed  surfaces,  and  swallowed,  is  sometimes  highly  ser- 
viceable ;  as  is  also  the  steam  of  water,  or  vinegar  and  water, 
applied  by  Mudge's  inhaler,  or  as  a  substitute,  a  common  tea- 
pot. 

1334.  But  should  the  disease  obstinately  run  its  course  to  sup- 
puration, (which  may  be  known  by  the  surface  becoming  of  a 
yellowish  hue,  and  by  a  throbbing,  and  a  disposition  to  rigour,) 
they  may  in  urgent  cases,  be  opened.     With  this  view,  emetics 
were  formerly  employed.     But  the  practice  is  painful  and  un- 
necessary, as  it  may  be  readily  done  by  puncture.     Having  dis- 
charged the  matter,  mild  detergent  gargles,  as  sage  tea,  honey, 

*  Take  a  tea-spoonful  of  Cayenne  pepper,  pour  on  it  a  gill  of  boiling  water; 
stir,  for  a  couple  of  minutes,  and  then  let  it  settle  clear — let  the  throat  be  gar- 
fled  with  a  portion  of  it  every  four  hours. 


CYNANCHE  TRACHEALIS,  OR  CROUP.  399 

and  vinegar,  should  be  directed  to  cleanse  the  parts,  and  to  dis- 
pose them  to  heal  kindly. 

1335.  As  regards  the  erysipelatous  species  of  the  disease,  the 
treatment  is  somewhat  different.     We  rely  more   on   topical 
bleeding,  and  the  vesicatory  applications;  and  where  aphthae  or 
sloughs  appear,  on  stimulating  gargles  ;  and,  in  the  event  of  ex- 
treme dibility  supervening,  the  system  is  to  be  supported  by 
bark,  wine,  the  carbonate  of  ammonia,  and  whatever  else  en- 
ters into  the  treatment  of  putrid  sore  throat. 

1336.  If  due  attention,  however,  be  paid  to  the  forming  stage 
of  this  disease,  it  can  very  frequently  be  arrested  in  limine  ;  for 
this  purpose  stimulating  external  applications  are  for  the  most 
part  efficient.     The  spirit  of  ammonia,  of  turpentine,  or  a  mix- 
ture of  the  flower  of  mustard  and  vinegar,  are  the  best.     They 
should  be  applied  immediately  over  the  throat,  and  should  be 
permitted  to  remain,  until  they  produce  decided  irritation;  they 
may  be  repeated  when  this  effect  disappears. 

1337.  To  such  children  as  are  subject  to  this  affection,  the 
above  directions  are  highly  important;  and  subsequent  returns 
may  often  be  prevented  in  those  that  can  gargle,  by  a  persevering 
use  of  alum  water,  or  an  infusion  of  Rut-galls,  in  the  proportion 
of  half  an  ounce  of  the  powder  to  a  pint  of  boiling  water;  and 
then  simmered  for  a  few  minutes.     This  must  be  strained  off, 
and  used  early  in  the  morning  and  on  going  to  bed.     We  have 
found  the  following  better,  in  warm  weather,  than  the  one  just 
suggested.     Pour  half  a  pint  of  brandy  or  whiskey,  and  as  much 
water,  upon  an  ounce  of  powdered  Aleppo  galls,  and  shake  them 
several  times  a  day,  for  a  few  .days — let  it  then  settle,  and  pour 
off  the  infusion  for  use.     With  a  quantity  of  this  the  throat 
should  be  gargled  the  first  thing  in  the  morning,  and  the  last  at 
night. 

SECT.  III. — CYNANCHE  TRACHEALIS,  OR  CROUP. 

1338.  It  is  not  essential  to  our  purpose  to  inquire  whether 
this  disease  was  known  to  the  ancients,  or  is  one  of  compara- 
tively modern  origin.     It  is  now  sufficiently  ascertained,  that  it 
is  one  of  too  common  occurrence  in  this  as  well  as  many  other 
countries,;  and  also  that  it  is  one  of  too  frequent  danger. 

1339.  This  complaint  is  almost  altogether  confined  to  the  pe- 
riod of  childhood,  and  is  most  frequent  in  infancy,  or  before  the 
fifth  or  sixth  year.      It  is  affirmed,  particularly  by  Cullen,  that 
this  disease  rarely  attacks  infants  till  they  are  weaned;  'and  that 
there  is  no  instance  of  its  occurring  in  children  above  twelve 
years  of  age.     As  a  general  rule  this  may  be  correct;  but  our 
experience  has  furnished  us  with  a  number  of  exceptions.     We 


400          CFNANCHE  TRACHEALIS,  OR  CROUP. 

have  seen  it  in  its  most  formidable  shape,  in  children  at  the 
breast;  and  we  have  witnessed  death  from  it  in  the  adult.* 

1340.  Children  of  a  florid  complexion,  and  enjoying  high 
health,  and  especially  those  inclined  to  be  fat  before  two  years, 
are  more  obnoxious  to  it  than  those  of  an  opposite  temperament. 
It  is  a  disease  of  more  frequent  occurrence  in  some  situations 
than  in  others;  and  those  which  are  near  waters  of  great  extent 
are  more  obnoxious  to  it  than  children  in  inland  situations ;  in  a 
word,  where  a  cold  and  moist  air  unite  ;  and  especially  when  it 
suddenly  alternates  with  a  dry  warm  air. 

1341.  Nothing  perhaps  can  be  more  satisfactorily  proved, 
than  the  agency  of  cold,  moist  air,  in  the  production  of  this 
complaint,  especially  in  the  spring  and  fall.    So  much  so  indeed 
is  this  the  case  in  certain  situations,  that  the  mothers  of  children 
who  are  disposed  to  this  disease,  dread  the  prevalence  of  that 
wind  which  shall  bring  with  it,  both.  Thus  in  this  city,  a  north- 
east wind  in  early  spring  or  fall,  is  almoat  sure  to  produce,  or 
reproduce  this  complaint,  in  those  who  are  disposed  to  it.     But 
with  such,  almost  any  sudden  transition,  which  too  suddenly  ar- 
rests perspiration  will  be  attended  by  the  same  consequences. 

1343.  Mechanical  causes  have  produced  a  disease  having  all 
the  characters  of  croup  from  other  causes ;  thus  Mr.  Balfour 
informed  Dr.  Home,  that  he  had  "  attended  a  child  in  a  disease, 
which  from  the  similarity  of  voice  appeared  to  him  to  be  croup. 
The  child  died.  When  opened,  a  piece  of  shell  which  the  child 
had  sucked  in  with  its  breath  was  lying  across  the  trachea,  about 
an  inch  below  the  glottis,  and  the  membrane  was  inflamed  and 
dry."  "  Here,"  continues  Dr.  Home,  "  was  an  artificial  croup 
raised,  from  which  we  may  evidently  perceive  how  the  voice  is 
altered  in  the  natural  disease,  "t 

1343.  This  disease  attacks  in  one  of  two  ways;  1st,  by  a 
hoarseness,  which  is  perceived  upon  coughing,  and  which  may 
continue  without  increase,  for  even  several  days,  or  until  per- 
haps the  sudden  application  of  some  exciting  cause ;  such  as  a 
change  in  the  temperature  of  the  air. 

*  "  The  croup  chiefly  prevails  in  children  from  a  short  time  after  birth  until 
puberty,  attaching  itself  to  particular  families."  Cheyne,  p.  15.  To  the  truth 
of  these  observations,  we  have  frequently  borne  witness.  But  we  have  seen 
this  complaint  after  puberty,  and  in  adult  age,  though  Dr.'  Cheyne  says  "  I  have 
heard  of  no  example  of  this  disease,  after  the  fifteenth  year."  He  says  further, 
"  I  have  imagined  this  to  depend  on  the  change  which  happens  in  the  consti- 
tution at  puberty,  and  perhaps  in  a  more  peculiar  manner  in  the  change  which 
the  upper  part  of  the  windpipe  undergoes."  This  is  ingenious,  and  probable; 
and  it  may  be  owing  to  this  circumstance,  that  it  is  a  rare  disease  in  adult  age; 
but  that  it  occurs  even  at  late  periods  of  life,  is  certain.  We  have  attended  a 
lady  within  the  last  six  years,  who  is  now  upwards  of  forty,  several  times, 
(certainly  five, )  with  threatening  attacks. 

f  Inquiry  into  the  Nature  and  Cure  of  Croup,  p.  49. 


'•    ^Jfaij        '  *••  ',•*>•'   •"', 

CYNANCHE    TRACHEALIS,    OR    CROUP.  401 

•• 

1344.  For  exposure  to  cold  and  damp,  or  a  check  to  perspi- 
ration, calls  forth  some  of  its  more  formidable  symptoms ;  as 
more  or  less  difficulty  of  breathing;  an  increase  of  cough  without 
expectoration  and  fever;  this  form  is  longer  running  its  course, 
than  the  one  about  to  be  mentioned,  but  is  less  obedient  to  the 
powers  of  medicine. 

1345.  Or  secondly,  it  may  attack  with  the  most  alarming 
suddenness  where  no  such  onset  was  suspected.  When  it  is  thus 
prompt  in  its  appearance,  it  menaces  life  from  the  moment  of  its 
invasion;  and  if  its  terrible  march  be  not  very  speedily  arrested, 
it  but  too  frequently  triumphs,  in  death. 

1346.  But  whether  the  croup  insidiously  steals  upon  its  vic- 
tim, or  suddenly  threatens  it;  the  latter  part  of  the  evening  after 
a  short,  but  rather  disturbed  sleep,  and  about  two  or  three  o'clock 
in  the  morning,  are  the  most  certain  periods  for  it  to  declare 
itself — hence,  the  frequency  of  our  first  attendance  during  the 
night.* 

1347.  With  the  exception  of  hoarseness,  we  have  never  ob- 
served any  premonitory  symptoms  to  this  disease;  for  we  cannot, 
with  propriety,  consider  a  slight  catarrhal  affection,  as  properly 
belonging  to  this  complaint,  though  it  may  occasionally  precede 
the  croupy  symptoms.     Cheyne's  account  is  rather  poetical  for 
ordinary  occurrence;  or  at  least  we  cannot  acknowledge  we  have 
ever  witnessed,  (and  our  own  family  has  furnished  us  unfortu- 
nately with  but  too  many  examples,)  that  the  patient  "shuns 
his  playfellows,  and  sits  apart  from  them,  dull,  and,  as  it  were, 
foreseeing  his  danger."  p.  16.     On  the  contrary,  we  have  seen 
many  instances,  where  this  disease  has  attacked  children,  and 
that  with  great  violence,  after  their  having  spent  their  evenings 
in  high  mirth,  and  merriment. 

1348.  It  must,  however,  be  confessed,  that  we  have  known 
children  indisposed,  and  dull,  from  catarrh,  previously  to  the 
attack  of  croup;  but,  in  these  instances,  the  latter  was  not  anti- 
cipated from  any  of  the  then  existing  symptoms;  consequently, 
this  previous  condition  did  not  necessarily  belong  to,  nor  pro- 
perly forerun,  the  latter.    We  believe  it  to  be  familiar  to  almost 
every  practitioner,  that  croup  may  supervene  upon  catarrh;  not 

*  Dr.  Cheyne  says,  "  The  disease  generally  comes  on  in  the  evening  after 
the  little  patient  has  been  much  exposed  to  the  weather  during  the  day,  and 
often  after  a  slight  catarrh  of  some  days  standing."  p.  15. 

The  evening  is  the  most  frequent  period  for  an  attack  of  this  complaint;  but 
for  this  purpose,  it  is  not  necessary,  that  the  "  little  patient"  shall  have  been 
"  much  exposed  to  the  weather;"  for  we  have  often  witnessed  this  disease 
from  the  mere  prevalence  of  a  north-east  wind,  and  where,  in  consequence  of 
this  wind,  every  precaution  has  been  taken  to  guard  against  its  influence,  by 
confining  the  child,  and  keeping  it  warm.  We  have  elsewhere  declared,  that 
catarrh  is  not  a  necessary  forerunner  of  this  complaint. 

51 


402          CYNANCHE  TRACHEALIS,  OR  CROUP. 

perhaps,  as  a  consequence,  ever,  but  as  a  coincidence:  for  catarrh 
is  owing  to  a  peculiar  condition  of  the  mucous  membrane  of  the 
nose,  and  windpipe;  and  for  croup  to  form,  or  grow,  out  of  this 
affection,  it  will  at  least  require  an  alteration  of  that  condition, 
and  not  a  mere  increase  of  its  force;  for  the  severest  catarrhs  we 
witness — catarrhs,  which  require  not  only  prompt,  but  extremely 
active  treatment,  croupy  symptoms  do  not  make  their  appear- 
ance as  a  necessary  consequence. 

1349.  In  this  opinion  we  are  happy  to  find  ourselves  con- 
firmed by  an  observation  of  the  celebrated  and  accurate  Laennec, 
whose  work  upon  the  diseases  of  the  chest  has  been  lately  most 
ably  translated  by  Dr.  Forbes.     He  says,   p.  120,  "the  false 
membrane  which  so  frequently  forms  on  blisters,  is,  of  itself, 
sufficient  to  prove  that  it  is  much  less  to  the  degree,  than  the 
nature  of  the  inflammation,  that  we  are  to  attribute  this  concre- 
tion or  coagulation  of  pus  in  certain  cases.     Indeed,  the  cause  of 
it  is  much  more  probably  to  be  attributed  to  some  peculiar  dis- 
position of  the  fluids,  than  to  any  affection  of  the  solids." 

1350.  From  this  it  would  appear,  that  it  is  not  sufficient  for 
the  production  of  croup,  that  the  mucous  membrane  of  the  wind- 
pipe be  merely  inflamed,  but  that  it  requires  a  modification  of 
inflammation  to  induce  it. 

1351.  It  may  be  further  observed,  that  during  the  prevalence 
of  catarrhal  affections,  croup  is  more  rife  than  at  other  periods; 
not  that  the  one  produces  the  other,  but  because  during  such  pe- 
riods as  the  spring  and  fall,  or  the  very  moist  and  open  weather 
of  winter,  there  is  a  stronger  disposition  created  to  these  dis- 
eases ;  and  that  they  have,  at  one,  and  the  same  time,  the  same 
exciting  causes. 

1352.  We  have  uniformly  observed  the  insidious  approach  of 
this  complaint,  to  be  less  under  the  controul  of  remedies,  if  its 
first  stage  be  neglected,  than  when  the  attack  is  sudden,  how- 
ever violent  that  attack  may  be.     This  is  doubtless  owing  to  its 
first  symptom,  hoarseness,  being  neglected.     For  this  reason  we 
would  wish  to  put  parents  upon  their  guard,    whenever  this 
symptom  lake  place;  by  assuring  them  from  long  experience, 
that  it  is  one  of  a  most  dangerous,  and  threatening  character. 
So  attentive  are  we  to  this  forewarning  in  our  own  family,  (and 
we  have  taught  others  to  be  equally  vigilant,)  that  it  is  attended  to 
immediately,  and  opposed  by  most  active  remedies;  and  we  have 
every  reason  to  believe,  that,  by  the  means  we  shall  recommend 
for  this  purpose,  we  have  stopped  this  formidable  complaint  in 
limine,  in  very  many  instances.     It  is  true,  a  hoarseness  passes 
off  sometimes,  without  much  mischief;  but  this  is  not  the  hoarse- 
ness of  croup;  for  this,  we  believe,  never  takes  its  leave  sponta- 
neously. 


CTNANCHE  TRACHEALIS,  OR  CROUP.          403 

1353.  The  hoarseness  which  disappears  spontaneously,  is  very 
distinct  from  that  of  croup  ;  the  difference,  however,  cannot  well 
be  conveyed  by  words,  unfortunately  sometimes,  for  those  who 
may  be  assailed  by  it.*     It  may,  however,  be  observed,  that 
there  is  a  certain  clearness  and  distinctness  in  the  croupy  sound, 
that  does  not  attend  the  other;  the  one,  (the  croupy,)  seems  as 
if  it  issued  from  a  metallic  instrument;  and  the  other  from  one 
of  a  less  vibrating  material.     The  ear,  however,  by  habit,  may 
learn  to  distinguish  between  them,  and  when  once  instructed,  it 
never  loses  its  discriminating  tact. 

1354.  We  may  also  observe  that  the  evanescent  hoarseness 
is  almost  always  accompanied  by  a  little  soreness  of  throat; 
while  that  of  croup,  we  believe,  is  never.     Again,  the  first  is 
perceived  in  common  speaking;  whereas  that  of  croup  is  only 
discoverable  in  the  commencement,  by  coughing.    Lastly,  some 
little  pain  and  soreness  are  observed  about  the  posterior  fauces 
after  coughing,  which  never  happens  in  that  of  the  croup.     It 
may  not  however  be  amiss  to  observe,  that  a  mere  loss  of  voice 
must  not  be  mistaken  for  croupy  hoarseness,  as  we  have  known 
it  to  be  on  several  occasions,  to  the  great  terror  of  an  anxious 
parent. 

1355.  In  this,  and  perhaps  every  other  country  where  croup 
is  of  frequent  occurrence,  every  sudden  difficulty  of  breathing, 
accompanied  with  cough,  in  children,  is  mistaken  for  this  dis- 
ease.    Thus,  the  acute  pituitous  catarrh  is  often  mistaken  for  it. 
Laennec  says  "  this  disease  is  characterized   by  an  extreme 
oppression  attended  by  a  copious  pituitous  expectoration.     It 
sometimes  begins  as  a  common  cold,  but  after  a  few  hours,  or 
even  minutes,  its  severe  character  is  soon  declared,  by  the  vio- 
lence of  the  cough,  the  intensity  of  the  dyspncea,  and  oppres- 
sion, the   lividity  of  the  face,   marks  of  cerebral  congestion, 
disordered  circulation,  and  coldness  of  the  extremities.    In  chil- 
dren it  is  sometimes  mistaken  for  croup."t 

1356.  But  it  may  be  proper  to  advise,  whenever  hoarseness 
takes  place,  not  to  trust  too  much  to  the  discriminating  powers 
of  the  ear,  for  its  nature;  but  instantly  to  proceed  upon  the  sup- 
position that  it  may  be  of  a  dangerous  kind,  especially  as  the 
remedies  employed  for  the  one  will  most  certainly  relieve  the 

*Dr.  Ferriar  observes,  (Med.  Hist.  Vol.  3,  p.  137,)  "  children  who  are  sub- 
ject to  croup,  are  sometimes  seized  With  the  deep,  barking  cough,  w,hich 
will  increase  to  such  a  degree  as  to  create  much  alarm,  about  the  usual  time 
of  the  dangerous  exacerbation;  yet  it  will  decrease  again,  and  at  length  g'o  en- 
tirely off,  without  any  other  remedies  than  common  demulcents.  Cases  of  this 
kind,  I  suspect,  have  been  described  as  genuine  paroxysms  of  croup,  and  very 
trifling  methods  of  cure  have  been  recommended,  in  consequence  of  their  ap- 
parent efficacy  in  the  spurious  croup,  which  always  cures  itself." 

f  Laennec  on  the  Chest,  Forbes's  Translation,  p.  80. 

t 


404          CYNANCHE  TRACHEALIS,  OR  CROUP. 

other.  It  is  therefore  erring  on  the  safer  side  to  treat  it  as  if  it 
were  of  a  mischievous  character,  though  it  might  have  passed 
away  without  such  treatment. 

1357.  It  would  seem  necessary  to  the  well  understanding  of 
the  progress  of  croup,  and  its  mode  of  treatment,  that  it  be  di- 
vided into  three  stages  ;*  1st,  the  forming  stage ;  2d,  the  com- 
pletely formed  stage ;  and  3d,  the  congestive  stage. 

Of  the  First  Stage. 

1358.  We  have  already  remarked,  that  one  of  the  first  and 
most  certain  signs  of  this  complaint  being  about  to  take  place, 
is  a  peculiar  sonorous  hoarseness,  when  the  patient  coughs,  but 
which  at  this  period  does  not  affect  the  speaking  voice;  this  pe- 
culiarity exists  for  a  longer  or  shorter  time,  without  much  in- 
crease, even  for  several  days  in  some  instances;  while  in  others, 
the  interval,  or  stage  of  formation  is  very  short,  but  very  de- 
cidedly marked.     This  hoarseness  may  in  some  instances  be 
accompanied  or  preceded  by  catarrhal  symptoms ;  but  not  neces- 
sarily.t    In  this  stage  when  not  attended  by  catarrh,  we  find  for 
the  most  part  the  circulatory  system  undisturbed,  and  the  respi- 
ratory not  confined,  nor  even  hurried.     The  child  in  general  is 
as  cheerful  as  usual ;  and  its  appetite  and  digestive  powers  are 
undiminished.     In  a  number  of  instances  where  the  disease  was 
making  an  insidious  attack,  we  have  seen  children  exert  them- 
selves even  pretty  violently,  without  creating  any  uncommon 

*  Dr.  Cheyne  divides  this  disease  into  but  two  stages;  1st,  "the  incomplete 
or  inflammatory;"  2d,  "  the  complete  or  purulent."  In  the  first,  "the  mem- 
brane is  not  yet  formed;  in  the  second  it  is  fully  formed."  This  division  does 
not  comprehend  the  whole  history  of  the  disease;  for  the  forming  stage  is  one 
of  the  greatest  importance  in  the  treatment  of  the  complaint,  and  therefore 
merits,  we  conceive,  the  distinction  we  have  given  it.  Besides,  we  cannot 
regard  Dr.  Cheyne's  second  stage  as  representing  this  disease  in  its  complete 
form;  since  the  whole  of  the  phenomena  of  that  stage  are  but  consequences 
of  the  previous,  or  his  "  incomplete  or  inflammatory."  And  he  himself  admits 
this,  in  several  places  of  his  lucid  and  excellent  essay. 

\  "  The  inflammatory  affection  of  the  larynx  is  doubtless  sufficient  to  ac- 
count for  the  alteration  which  takes  place  in  the  sound  of  the  voice  and 
cough."  Cheyne,  p.  22. 

We  believe  there  is  in  most  instances  an  intermediate  condition  of  the  la- 
rynx, in  the  commencement  of  this  disease;  which  is  a  degree  of  excitement 
in  the  part,  accompanied  by  a  little  thickening  of  the  mucous  membrane;  but 
which  does  not  absolutely  amount  to  inflammation;  for  could  not  hoarseness 
be  produced  by  any  thing  short  of  inflammation,  there  could  not  be  that  spe- 
cies of  croup,  which  Dr.  Ferriar  and  Dr.  Cheyne  himself  admit  the  existence 
of,  namely,  the  "spurious  croup,"  (see  note  to  par.  1353.)  We  are  further 
disposed  to  believe  in  this  condition  of  the  trachea,  or  larynx,  in  consequence 
of  the  very  speedy  removal,  in  many  instances,  of  this  symptom,  when  suffi- 
ciently and  promptly  attended  to,  by  the  remedies  recommended  for  the  first 
stage  of  this  complaint. 


CYNANCHE  TRACHEALlS,  OR  CROUP.         405 

hurry  in  the  breathing,  or  occasioning  in  it  the  slightest  embar- 
rassment ;  yet  these  very  children,  in  the  course  of  a  few  hours, 
were  reduced  to  the  last  extremity  ;  and  some  of  them  did  not 
escape  with  life. 

1359.  We  think  we  have  observed,  however,  in  this  forming 
stage,  especially  in  the  insidious  attacks,  the  hands  to  be  more 
than  usually  cool;  the  face  to  be  rather  unnaturally  pale;  and  the 
skin  to  resemble  in  a  small  degree,  the  cold  stage  of  an  intermit- 
tent, but  not  attended  by  a  sense  of  cold :  this  state  of  collapse 
remains  for  several  hours  in  some  instances,  before  the  system 
is  roused  to  reaction.  But  where  the  attack  is  sudden,  we  are  by 
no  means  certain,  that  this  condition  always  precedes  the  fe- 
brile state,  which  so  frequently  is  awakened,  and  made  to  ac- 
company this  complaint. 

1360.  During  this  period  however,  the  mucous  membrane  of 
the  nose  is  observed  to  be  affected ;  since,  the  secretion  in  the 
nostrils  is  either  arrested  altogether,  or  very  much  diminished ; 
and  continues  to  be  so  during  the  whole  course  of  the  disease, 
unless  it  terminate  favourably.     The  cough  is  short,  dry,  and 
sonorous;  or  if  any  thing  be  expectorated,  it  is  thin  and  whitish, 
and  in  very  small  quantities. 

1361.  If  the  throat,  or  fauces  be  inspected,  nothing  unusual, 
(at  least  as  far  as  we  have  observed,)  shows  itself.     The  back 
part  of  the  tongue,  is  perhaps  more  loaded  than  is  natural,  but  it 
is  far  from  being  remarkable.* 

1362.  After  the  continuance  of  the  above  symptoms  for  a 
longer  or  shorter  time,  a  change  takes  place,  by  an  aggravation 
of  all  of  them;  and  at  the  same  time,  others  are  added;  and  these 
will  constitute  the 

Second  stage,  or  that,  in  which  the  Disease  is  completely 

formed. 

1363.  At  this  time  we  observe  the  hoarseness  to  be  increased, 
and  to  affect  the  speaking  voice  ;t  that  is,  the  tone  of  hoarseness 
is  evidently  deeper,  more  ringing,  and  betrays  itself  in  every 
attempt  to  speak;  the  cough  is  more  frequent  and  the  spells 
longer:  a  degree  of  exhaustion,  attended  by  an  increase  of  the 
difficulty  of  breathing,  follows  each  effort;  the  face  becomes 

*  "  When  in  the  urgency  of  the  attack,  the  fauces  and  neck  are  examined 
with  a  view  to  investigate  the  cause  of  the  symptoms,  (hoarseness,  &c.)  even 
when  a  sense  of  heat  is  complained  of  in  the  throat,  the  tonsils  are  not  swelled, 
and  but  little  inflamed."  Cheyne,  p.  18. 

•(•  It  may  be  remarked  as  a  general  rule,  that  where  the  voice  becomes  sud- 
denly affected  by  hoarseness,  which  discovers  itself  in  speaking,  and  withou* 
being  so  in  coughing,  that  it  is  not  the  hoarseness  of  croup.  This  kind  of 
hoarseness,  however,  is  more  common  to  adults  than  children. 


406          CYNANCHE  TRACHEALIS,  OR  CROUP. 

flushed  during  the  coughing ;  but  generally  subsides  as  the  cir- 
culation becomes  more  equal,  after  the  exertion,  but  leaves  the 
cheeks,  or  perhaps  only  one  redder  than  natural.*  The  circula- 
tion is  now  much  hurried  in  most  cases ;  at  other  times  it  is  very 
little  disturbed ;  when  this  latter  is  the  case,  the  face  is  seldom 
flushed,  and  the  hands  and  skin  of  the  extremities  are  rather  be- 
low the  natural  standard  of  heat.  The  child  is  drowsy,  and  falls 
into  frequent,  but  disturbed  slumbers,  from  which  it  is  generally 
roused,  by  the  most  heart-rending  cough,  and  an  increase  of  op- 
pression. The  child  raises  itself  up,  if  sufficiently  old  to  do  so ; 
or  if  not,  elevates  its  head,  with  a  desire  more  freely  to  gain  air. 
This  state  of  things  does  not  last  long;  for  if  the  progress  of  the 
disease  be  not  arrested  here,  it  marches  with  rapid  strides  to  the 

Third  or  Congestive  Stage. 

1364.  At  this  period,  the  cough  is  attended  with  some  ex- 
pectoration of  a  thin  frothy  mucus,  which  affords  no  relief;  it  is 
more  frequent  in  its  recurrence,  and  more  permanent  in  its  du- 
ration ;  sometimes  so  much  so  as  to  threaten  strangulation — the 
child  becomes  much  exhausted  by  these  efforts,  and  throws  itself 
back  as  if  in  despair,  but  from  which  it  instantly  springs,  from 
the  feeling  or  dread  of  instant  suffocation.     It  cannot  now  lie 
down;  and  it  either  throws  its  head  much  in  advance,  as  in  asthma, 
or  bends  itself  very  much  backward  ;  or  it  finds  no  relief  but  in 
a  supine  position,  and  that  to  all  appearance  the  most  unfavoura- 
ble to  easy  breathing.     It  is  restless  in  the  extreme ;  and  alter- 
nately tries  every  position,  without  finding  relief  from  any. 

1365.  The  face  is  no  longer  flushed;  a  dark  lividity  takes  its 
place,  which  sometimes  spreads  itself,  even  to  the  neck;  the  lips 
partake  of  this  change ;  and  the  gums  become  pale  and  white, 
while  the  tongue  is  not  unfrequently  blackish,  as  if  the  blood 
were  retained  in  it  by  a  ligatare.  The  forehead  becomes  shining, 
and  the  skin  looks  as  if  it  were  tightly  stretched  over  it — it  is 
wet  with  cold  perspiration,  as  is  now  indeed  almost  every  part 

•  There  cannot  we  believe,  exist  a  doubt,  of  the  condition  of  the  mucous 
membrane  of  the  trachea  at  this  time — every  thing- would  seem  to  declare  it  to 
be  in  a  state  of  active  inflammation.  The  formation  of  a  deciduous  membrane, 
which  is  sometimes  thrown  up,  or  after  death  proved  by  dissection  to  exist, 
and  even  the  remains  of  turgid  vessels  in  this  part,  all  announce  inflammation 
of  an  active  kind  to  constitute  the  proximate  cause  of  this  disease. 

The  following  is Laennec's  " Anatomical  Characters"  of  croup.  "Croup 
is  an  inflammation  of  the  mucous  membrane  of  the  air-passages,  with  exuda- 
tion of  plastic  pus,  (coagulable  lymph,)  which  becoming  concrete  at  the  very 
moment  of  its  formation,  lines  the  surface  of  this  membrane  to  a  greater  or  less 
extent;  when  this  false  membrane  is  removed,  the  subjacent  tunic  is  found  of 
a  deep  vivid  red  colour,  occasionally  livid,  and  somewhat  thickened."  p.  119. 


CTNANCHE    TRACHEALIS,   OR   CROUP.  407 

of  the  body ;  the  hands  death-cold,  and  black  blood  is  settled  at 
the  extremities  of  the  fingers  and  nails. 

1366.  The  pulse  is  small,  frequent,  fluttering,  and  contracted. 
The  heart  beats  with  violence,  nay  sometimes  audibly.     The 
auxiliary  muscles  of  respiration,  are  now  called  into  requisition, 
and  this  process  seems  only  maintained  by  their  aid ;  a  deep 
hollow  is  made  immediately  below  the  xiphoid  cartilage,  most 
probably  by  the  severe  contraction,  or  efforts  of  the  diaphragm  ; 
and  the  action  of  the  heart  is  distinctly  seen,  even  at  a  distance 
from  its  seat. 

1367.  Though  the  cough  is  now  more  frequent,  and  the  op- 
pression much  increased,  the  hoarseness  is  neither  so  great  nor 
so  sonorous.     It  is  now  almost  an  entire  loss  of  voice,  and  the 
child  when  it  speaks,  seems  to  employ  for  this  purpose  a  loud 
whisper.    Even  when  it  coughs,  the  voice  is  less  harsh ;  or  rather 
it  has  lost  in  a  degree,  that  appalling,  brazen,  vibratory  sound, 
with  which  the  two  first  stages  are  attended.     This  change  of 
tone  of  the  voice  has  but  too  often  misled  the  inexperienced  ear 
to  the  belief,  that  the  disease  was  yielding;  and  thus  have  given 
rise  to  hopes,  that  were  but  too  soon  to  be  blasted  forever. 

1368.  This  cessation  of  the  croupy  sound,  is  no  less  remarka- 
ble than  delusive;  for  it  suggests  to  the  inexperienced,  the  hope  of 
improvement  just  mentioned ;  we  confess  we  were  once  betrayed 
into  a  similar  belief,  only  to  be  more  severely  disappointed — but 
we  are  never  imposed  upon  now — we  mention  this,  because  it  is 
a  block  over  which  all  young  practitioners  stumble.     Dr.  Watt 
we  think  accounts  for  this  change  satisfactorily  ;  he  says,  "  it  has 
been  remarked  by  some  of  the  writers  on  croup,  that  in  various 
cases,  the  disease  proves  fatal  without  having  any  thing  of  the 
croupy  voice,  and  yet  the  adventitious  membrane  is  found  in  a 
more  or  less  perfect  state.     In  others,  where  the  croupy  voice 
was  completely  formed,  it  has  gone  off  some  time  before  death, 
and  yet  the  membrane  was  found  entire." 

1369.  "In  the  first  instance,  the  air-cells  and  bronchi®  were 
probably  affected  as  soon  or  sooner  than  the  trachea ;  hence  the 
difficulty  of  producing  a  vacuum,  increased  with  the  difficulty  of 
admitting  air;  and  thus  the  one,  always  being  in  proportion  to 
the  other,  the  patient  might  appear  in  danger  of  suffocation,  but 
the  symptoms  of  strangulation  never  could  be  the  consequence. 
In  the  last  instance,  we  have  only  to  suppose  the  inflammation 
began  at  the  top  of  the  windpipe,  and  gradually  extended  down- 
wards.    At  the  commencement  of  such  a  case,  signs  of  strangu- 
lation would  appear ;  because  the  cells  could  take  in  more  air  in 
a  given  time,  than  the  glottis  could  admit;  hence  the  stridulous 
croupy  sound  in  inspiration.     But  by  and  by,  as  the  disease  ex- 
tended downwards,  and  the  accumulation  of  mucus  took  place, 


408          CYNANCHE  TRACHEALIS,  OR  CROUP. 

the  difficulty  of  producing  a  vacuum  came  to  equal  or  exceed  the 
difficulty  of  admitting  air,  and  then  the  croupy  stridulous  noise 
ceased,  as  the  noise  ceases,  on  admitting  air  into  the  vacuum  of 
an  air  pump,  when  the  equilibrium  is  nearly  restored."  p.  136. 

1370.  Thirst  oftentimes  becomes  so  intolerable,  as  to  render 
the  demands  for  drink  both  frequent  and  clamorous,  though 
every  attempt  to  gratify  it,  is  apparently  at  the  risk  of  suffoca- 
tion.    The  countenance  is  now  anxious  beyond  expression ;  the 
eyes  become  most  piercingly  brilliant,  and  beseeching — and  elo- 
quently implore  a  relief,  which  neither  affection,  nor  science,  can 
afford ;  and  the  poor  sufferer  expires,  with  a  look,  full  of  suppli- 
cation and  anguish.* 

1371.  This  disease  runs  its  course  variously;  sometimes  it 
lingers  for  days,  while  at  others,  its  career  is  finished  in  a  few 
hours.     This  variety  in  termination  will  depend  upon  the  con- 
stitution ;  upon  the  period  at  which  remedies  were  applied ;  upon 
the  nature  of  the  remedies,  and  their  power  or  influence  upon 
the  system. 

1372.  Dissection  proves  this  disease  to  kill  in  many  instances 
by  suffocation,  from  a  mechanical  cause ;  at  other  times,  no  such 
obstruction  can  be  found — therefore  pathologists  declare  spasm 
to  be  the  cause,  where  the  mechanical  one  is  not  present.     This 
by  some  has  been  extended,  even  to  the  formation  of  a  distinct 
species  of  croup ;  namely,  the  spasmodic  ;  a  kind  we  have  never 
witnessed.   By  others,  this  has  been  modified  ;  and  the  pathology 
of  croup  made  to  consist  in  inflammation  and  spasm  united.  We 
do  not  believe  in  the  presence  of  spasm,  in  either  of  the  two  first 
stages  of  this  complaint ;  it  may  take  place,  and  probably  does, 
sometimes  in  the  last. 

1373.  "Dr.  Marcus,  of  Bamberg,  in  Bavaria,  looks  upon  all 
fevers  as  inflammation  of  some  one  organ  or  other,  and  as  en- 
tirely seated  in  the  arterial  system,  regards  croup  as  a  local  in- 
flammation alone,  utterly  independent  of  spasm,  which  neither 
exists  here  nor  in  fever  of  any  kind."t 

1374.  Some  have  disputed  the  formation  of  a  membrane  within 
the  trachea ;  but  it  can  only  be  by  those  who  are  not  in  the  habit 
of  investigating  diseases  by  dissection.     We  have  seen  it  more 
than  once,  and  of  course  we  are  convinced  of  its  existence. 
Others  who  will  not  venture  to  deny  the  presence  of  a  foreign 
body  within  the  trachea,  deny  it  to  be  a  membrane;  they  declare 

*  We  have  sometimes  seen,  a  short  time  before  death,  the  little  patient  lie 
on  its  back  apparently  resigning  itself  to  a  fate,  against  which  it  could  no 
longer  struggle,  and  eventually  expire,  and  this  with  a  complacency  that 
would  create  the  belief,  that  its  sufferings  had  terminated,  before  death  had 
relieved  them. 

t  Good's  Study  of  Medicine,  Am.  Ed.  Vol.  II.  p.  235. 


crNANCHE  TRACHEALIS,  OR  CROUP.          409 

it  to  be  nothing  but  inspissated  mucus,  and  not  a  membranous 
product.  At  this  day,  there  can  be  nothing  new  in  the  declara- 
tion, that  if  lymph  be  poured  out  from  vessels  in  a  certain  state 
of  action,  upon  either  exposed  surfaces  or  within  cavities,  but 
especially,  mucous  surfaces,  that  it  will  form  membrane;  the 
pleurae  and  the  peritoneum  also  furnish  almost  daily  examples 
of  this  kind.*  This  false  membrane  extends  from  below  the 
larynx  to  the  bronchial  ramifications;  and  we  once  saw  it  within 
them. 

1375.  Laennec,  p.  120,  says  "the  false  membrane  of  croup 
corresponds  exactly  with  the  form  of  the  canals  which  it  covers. 
Its  thickness  is  usually  somewhat  greater  in  the  larynx  and  tra- 
chea than  in  the  bronchia,  and  varies  from  less  than  half  a  line 
to  a  line.     Its  consistence  is  that  of  boiled  white  of  egg,  but  this 
usually  diminishes  towards  its  extremities,  so  that  it  becomes 
sometimes  in  this  situation  scarcely  more  solid  than  the  thick 
phlegm  of  catarrh.     It  is  of  a  white  colour  with  sometimes  a 
shade  of  yellow,  and  is  almost  entirely  opaque." 

1376.  Dr.  Watt  has  given  us  an  account  of  the  result  of  his 
observations  on  the  condition  of  the  parts  both  directly  and  in- 
directly involved  in  this  disease.     He   says,   "in  dissections 
that  have  been  made  in  croup,  it  is  always  mentioned,  that  be- 
sides the  adventitious  membrane  at  the  top  of  the  windpipe, 
there  was  found  a  great  quantity  of  semi-purulent  fluid  in  the 
under  part  of  the  trachea,  or  in  its  more  minute  ramifications. 
Now  I  presume,"  the  Dr.  continues,  "  that  the  accumulation  of 
this  fluid  is  oftener,  the  immediate  cause  of  death,  than  the  mem- 
brane itself;  and  that  it  is  always  so,  when  the  symptoms  of 
strangulation  and  crowing  disappear  before  the  fatal  event."  p. 
139. 

1377.  Connected  with  this  subject,  the  Dr.  mentions  another 
curious,  and  to  us,  novel  fact.    "  In  both  of  the  two  cases  I  have 
related,  it  is  mentioned,  that  the  surface  of  the  lungs  were  irre- 
gularly covered  with  whitish  spots,  slightly  elevated.  On  speak- 
ing of  this  circumstance  to  Mr.  Allan  Burns,  he  mentioned, 
that  it  was  not  a  very  uncommon  appearance;  he  had  met  with 
it  often."  "It  seemed,"  he  remarked,  "to  be  always  connected 
with  an  inflamed  state  of  the  lungs  themselves,  or  of  the  passages 

*  When  this  substance  is  chemically  examined,  "  the  secretion  appears  to 
consist  chiefly,  if  not  entirely  of  the  gluten  or  coagulable  lymph  of  the  blood, 
diluted  with  its  serosity  and  copiously  combined  with  that  peculiar  substance 
of  the  blood  which  has  received  the  name  of  fibrin." — Good's  Study  of  Medi- 
cine, Am.  Ed.  Vol.  II.  p.  234. 

"  It  is  a  little  singular  that  children  should  be  chiefly  subject  to  its  attack, 
at  whose  age  fibrin  is  not  peculiarly  abundant,  and  whose  blood  contains  com- 
paratively but  a  small  portion  of  azote,  which  in  fibrin  is  so  large  a  constitu- 
ent.''—!^ 

52 


410  CYNANCHE  TRACHEALIS,  On  CROUP. 

leading  to  them.     It  was  commonly,  if  not  always,  to  be  found 
in  subjects  who  had  died  of  croup."  p.  140. 

1378.  From  what  has  been  said,  it  will  be  evident,  that  nothing 
but  the  use  of  very  active  remedies  can  arrest  the  progress  of  this 
disease;  and  for  them  to  be  availing,  they  must  be  employed 
sufficiently  early,  to  prevent  the  inflamed  lining  of  the  trachea 
from  relieving  itself  by  effusion.     For  when  this  happens,  the 
case  for  the  most  part,  is  hopeless;  though  some  few  instances 
have  occurred,  where  recovery  took  place  after  its  formation — 
but  their  rarity,  only  shows  the  little  we  have  to  hope  at  this 
stage,  and  the  importance  of  early  attention  to  this  disease. 

1379.  It  is  now  so  generally  admitted  that  this  is  a  local  dis- 
ease, and  one  consisting  in  an  active  inflammation  of  a  highly  im- 
portant part,  that  there  is  scarcely  any  dispute  as  to  the  general 
mode  of  treating  it,  though  there  may  be  some  variety  in  the 
detail,  and  the  agents  intended  to  fulfil  the  same  obvious  indica- 
tions.   Therefore,  with  a  view  to  the  better  illustrating  the  par- 
ticular mode  of  treatment,  we  shall  follow  the  stages  we  have 
made  this  disease  to  consist  of,  and  shall  begin  with  the  mode 
of  treating  the 

First  Stage. 

1380.  If  proper  attention  were  paid  to  the  timely  application 
of  appropriate  remedies  in  the  forming  stage  of  croup,  we  have 
every  reason  to  believe,  that  this  complaint  could  be  stopped  in 
limine,  in  nineteen  cases  out  of  twenty.     It  is  to  the  ignorance 
of  what  a  hoarseness,  when  it  first  shows  itself,  may  lead  to, 
that  this  obvious  and  almost  certain  symptom  is  neglected;  and 
to  this  neglect,  must  be  attributed,  the  often  fatal  termination  of 
croup. 

1381.  A  sufficient  experience  justifies  us  in  the  declaration 
just  made;  and  the  same  experience  will,  we  trust,  screen  us 
from  the  imputation  of  becoming  alarmists,  when  we  declare, 
that  no  hoarseness  in  children  can  be  neglected,  but  at  the  risk 
of  life. 

1382.  We  can  call  to  mind  but  too  many  instances  of  fatal 
issue  where  this  friendly  warning  was  unheeded,  because  its  ten- 
dency was  not  understood.      Our  anxiety  to  abridge  the  ravages 
of  this  terrible  disease,  has  led  us  to  dwell  upon  this  point  longer 
than  would  be  necessary  for  the  mere  medical  reader;  but  we 
hope  he  will  excuse  us  for  cautions,  which  though  not  necessary 
to  him,  may  be  very  important  to  others,  who  may  honour  this 
work  with  a  perusal. 

1383.  It  has  been  our  misfortune  to  have  witnessed  but  too 
much  of  this  disease;  and  unhappily  too  much  in  our  own  imme- 


411 

diate  family.  We  were  early  instructed  in  all  its  phenomena; 
and  but  too  sorely  taught  its  deadly  tendency.  Our  misfortunes 
made  us  vigilant,  and  tremblingly  apprehensive  to  every  thing 
connected  with  this  disease,  especially  its  formation.* 

1384.  But  perhaps,  we  have  derived  advantages  from  oui 
losses;  and  most  happy  shall  we  be,  if  they  can  be  made  subser- 
vient to  the  general  good. 

1385.  For  many  years  nothing  could  exceed  our  horror,  when 
\called  to  attend  a  case  of  croup — for  our  too  faithful  ears  could 

f  not  forget,  the  appalling  sound  of  its  breathing;  alas!  they  were 
;  instructed,  by  instances  of  such  endearment,  that  memory  was 
{  almost  a  curse. 

1386.  We  were  thus  forced  to  a  knowledge  of  the  rise,  pro- 

gress,  and  issue  of  the  croup — would  we  could  add,  we  were  ^    -^ 
equally  well  instructed  in  the  management  of  all  its  stages—to  £J?  ?/"* 
this  however  we  make  no  particular  pretensions ;  though  we 
think  we  have  arrived  at  some  certainty  in  arresting  its  march.  *'< 
Our  particular  horror  of  croupy  hoarseness,  led  us  necessarily 
after  a  time,  to  the  very  early  application  of  remedies  for  its  re- 
moval— hence  for  the  last  twenty  years  we  have  never  suffered 
it  in  our  own  family,  to  exist  a  single  hour,  without  an  effort  to 
stop  it,  and  so  far  always  successfully. 

1387.  As  this  disease  most  commonly  attacks  in  the  night, 

we  have  ever  at  hand,  the  remedies  about  to  be  mentioned,  that   f  ^ 
a  moment  may  not  be  lost  in  their  application.     It  is  therefore 

*  The  ear  of  one  who  has  lost  a  child  with  this  complaint,  becomes  so  ex- 
tremely sensitive,  that  it  instantly  gives  the  alarm,  so  soon  as  hoarseness  is 
perceived,  which  sometimes  lead  to  an-interference,  that  would  perhaps  not  , 
be  justified  upon  any  other  occasion.  J^To  illustrate  this,  and  to  show  how  the  \ 
feelings  may  be  impelled  under  such  circumstances,  we  will  relate  an  anecdote    I 
which  befel  ourselves.  Passing  a  house,  towards  evening,  in  one  of  our  streets,    f 
our  ears  were  assailed  by  a  hoarse  cough,  which  proceeded  from  a  shivering    ; 
little  boy  of  about  three  years  old,  who  was  at  the  door,  but  which  was  shut    ' 
against  him. 

He  appeared  very  cold;  it  was  a  drizzly  evening,  and  the  month  was  No- 
vember. At  this  time  our  loss  of  an  only  child  with  croup  was  recent;  and  we 
were  labouring  under  all  the  wretchedness  such  a  loss  could  inflict,  and  of  % 
course,  were  peculiarly  sensitive  to  any  thing  which  reminded  us  of  a  disease 
which  had  created  for  us  so  much  misery.  We  knocked  at  the  door,  and  beg-  * 
ged  to  see  the  mother  of  the  child;  the  person  before.us  proved  to  be  the  one  -. 
we  wished  to  see.     We  represented  to  her  the  dangerous  situation  her  little 
boy  appeared  to  be  in,  and  begged  she  would  immediately  send  for  her  family 
physician,  to  visit  the  child,  and  advised  what  we  judged  proper  to  be  done, 
until  he  should  arrive.     The  mother  laughed  at  our  fears;  said  it  was  nothing 
but  "a  little  cold  the  child  had  taken,"  and  declared  "he  would  be  well 
enough  in  a  day  or  two,  without  any  doctor  stuff." 

We  took  our  leave;  but  feeling  interested  for  the  child,  we  went  next  day 
to  inquire  for  him;  and  was  told  by  a  next  door  neighbour,  that  he  had  died 
early  that  morning  of  "  hives;"  our  feelings  can  be  better  imagined,  than 
described. 


412  CTNANCHE  TRACHEALIS,  OR  CROUP. 

our  constant  habit,  the  instant  we  observe  the  croupy  sound,  to 
inflame  the  external  throat  by  the  application  of  the  spirit  of  tur- 
pentine, hartshorn,  or  mustard  and  vinegar.  This  we  repeat  if 
the  first  has  not  subdued  the  hoarseness,  so  soon  as  the  rubefa- 
cient  effect  has  subsided;  for  it  may  be  proper  to  observe,  we  do 
not  carry  the  stimulation  to  blistering.  In  aid  of  the  external 
applications,  we  administer,  in  doses  suitable  to  the  age  of  the 
child,  "the  compound  syrup  of  squills,"  or  "Coxe's  hive  syrup/' 
as  an  expectorant,  or  if  necessary,  as  an  emetic. 

1388.  If  the  hoarseness  do  not  yield  to  the  turpentine  or  to 
the  expectorant  doses  of  the  syrup,  we  urge  the  latter  by  quickly 
repeating  the  dose,  to  an  emetic  effect;  but  this  is  rarely  neces- 
sary, if  the  complaint  has  been  taken  early ;  or  if  the  throat  has 
been  well  inflamed.     For  we  can  most  truly  declare,  we  have 
very  often  seen  this  disease  subdued  in  an  hour  or  two.     But 
should  the  hoarseness  not  disappear,  though  much  diminished, 
we  continue  the  use  of  the  syrup,  until  it  does.     Should  the 
bowels  be  confined,  we  give  a  dose  of  castor  oil,  in  aid  of  the 
general  intention. 

1389.  With  the  same  intention,  we  regulate  the  diet,  or  rather, 
make  it  consist  of  barley  water,  or  flaxseed  tea ;  we  confine  the 
patient  to  an  atmosphere  of  moderate  temperature,  and  most  se- 
dulously guard  him  against  exposure,  or  a  draught  of  air.     The 
throat  must  be  protected  by  a  piece  of  flannel,  or  some  other 
warm  covering,  after  the  turpentine  or  mustard  has  been  re- 
moved. 

1390.  It  is  truly  astonishing,  with  what  certainty  this  plan 
arrests  this  disease,  in  by  far  the  greater  number  of  cases.     An 
experience  of  many  instances  fully  justifies  our  commendation  of 
it.    We  therefore  earnestly  advise  every  mother,  and  especially 
those  who  may  have  children  subject  to  this  complaint,  to  have 
immediately  at  command,  the  articles  just  mentioned,  and  to 
employ  them,  as  just  directed,  the  instant  hoarseness  may  ap- 
pear.    If  this  be  faithfully  attended  to,  we  shall  rarely  have  an 
opportunity  to  prescribe  for 

The,  Second  Stage. 

1391.  It  may  however  happen,  that  the  plan  just  suggested 
may  not  be  availing;  that  the  proper  time  for  their  application 
has  been  lost ;  or  that  we  have  not  seen  the  patient  until  the  se- 
cond stage  has  been  completely  formed;  in  either  of  these  events, 
we  are  obliged  to  prescribe  for  the  case  as  it  presents  itself.  We 
shall  find  the  system  in  the  second  stage,  in  one  of  two  condi- 
tions; namely,  1st,  where  the  disease  is  completely  formed  as 
regards  the  state  of  the  trachea,  but  without  the  arterial  system 


CYNANCHE  TRACHEALIS,  OR  CROUP.  413 

being  much  affected;  or,  2d,  where  the  action  of  the  arterial  sys- 
tem is  much  exalted,  in  consequence  of  the  inflammation  of  the 
trachea. 

1392.  These  two  conditions,  in  our  opinion,  require  some 
difference  in  the  mode  of  treatment ;  and  first  of  that  condition, 
where  the  blood-vessels  of  the  system  at  large,  are  not  much 
affected. 

1393.  In  this  case,  the  force  of  the  disease  is  mainly  spent 
upon  the  organs  immediately  concerned  in  respiration  ;  hence 
the  cough  is  more  frequent,  nay  sometimes  almost  incessant;  the 
hoarseness  less  deep  but  more  sonorous,  and  vibrating ;  no  ex- 
pectoration, or  in  a  very  trifling  degree,  and  that  of  unconcocted 
serum,  the  discharge  of  which,  affords  no  relief.     The  face  for 
the  most  part,  rather  pale,  or  partially  flushed ;  the  nostrils  very 
dry ;  the  temperature  of  the  hands  and  skin,  generally  rather 
below  the  natural  standard  ;  the  eyes  somewhat  blood-shotten ; 
the  pulse  frequent  and  small;  the  respiration  laborious,  and  every 
hour  becoming  more  and  more  so. 

1394.  In  this  situation,  we  have  thought,  the  remedy  so  ex- 
clusively relied  upon  by  many,  namely,  blood-letting,  always  to 
be  injurious,  or  certainly  never  beneficial — we  therefore  cannot, 
agreeably  to  our  present  impressions,  recommend  it;  since  un- 
der such  circumstances,  we  never  now  employ  it,  either  gene- 
rally or  topically. 

1395.  We  always  commence  the  treatment,  with  stimulating 
applications  to  the  throat ;  and  quickly  administer  a  brisk  emetic 
of  the  tartrite  of  antimony;  or  should  it  be  immediately  desira- 
ble to  procure  evacuations  from  the  bowels,  we  combine  with  it 
liberal  doses  of  calomel,  according  to  the  following  formula,  for 
a  child  of  two  years  old  or  rather  more. 

R.     Tartrite  of  antimony         -         -         gr.     ij. 
Calomel  prepared     -  -         gr.   xij. 

These  to  be  intimately  mixed  and  divided  into  eight  parts — one 
of  these  to  be  given  every  twenty  minutes,  or  half  hour,  mixed 
in  a  little  thin  syrup,  until  an  emetic,  and  cathartic  effect  be  pro- 
duced. Should  it  prove  pretty  powerfully  emetic,  we  make  the 
intervals  longer;  that  is,  once  an  hour;  and  more  seldom  in  pro- 
portion to  the  effect,  until  the  bowels  are  freely  moved,  or  even 
purged,  or  we  vomit  with  full  doses  of  the  hive  syrup.  With 
this  article  we  become  constantly  more  and  more  satisfied — for  if 
our  observations  do  not  deceive  us,  it  exerts  a  much  more  satis- 
factory influence  than  any  other  emetic  we  have  ever  employed. 
Does  the  honey  give  any  valuable  power  to  the  tartrite  of  an- 
timony ?  (We  have  given  a  formula  for  this  syrup,  in  our  chap- 
ter on  Hooping-cough.) 

1396.  After  the  medicine  has  operated  freely,  we  order  the 


414  CTNANCHE  TRACHEALIS,  OR  CROUP. 

hive  syrup  in  suitable  doses,  every  half  hour,  or  hour,  or  more 
seldom,  as  the  effect  may  be  more  or  less  ample.  Should  the 
disease  not  have  yielded  to  this  discipline,  we  give  calomel  in 
pretty  large  quantities,  every  two  hours,  as  long  as  the  bowels 
will  bear  it,  without  being  too  much  purged;  always  recollect- 
ing that  the  expectorant  doses  of  the  hive  syrup  are  not  to  be 
discontinued,  without  there  is  much  nausea. 

1397.  If  the  above  remedies  make  an  adequate  impression 
upon  the  disease,  an  abatement  of  all  the  unpleasant  symptoms 
will  take  place,  and  give  us  some  assurance  of  a  favourable  issue. 
In  the  condition  of  the  system  now  under  consideration,  we  must 
not  neglect  to  observe,  that  we  reckon  upon  the  favourable  signs, 
a  greater  warmth  of  skin,  with  a  slight  disposition  to  perspira- 
tion, and  an  increase  of  force,  and  vigour  in  the  circulating  sys- 
tem ;  for  when  these  take  place  there  is  less  risk  of  its  running  on 
to  the  congestive  stage,  or  at  least  this  period  is  delayed.     Be- 
sides, this  change  is  an  evidence  of  the  disease  being  now  less 
concentrated,  and  that  the  system  can  now-  bear  further  deple- 
tion, with  advantage,  should  it  be  judged  necessary.    This  is  so 
decidedly  the  case  Sometimes,  that  we  can  with  much  profit  to 
our  patient,  abstract  blood,  either  from  the  system  generally,  or 
from  near  the  parts,  by  cupping.   In  a  word,  the  disease  is  now 
converted  into  the  second  condition;  or  where  the  arterial  action 
is  much  exalted. 

1398.  In  this  second  state  of  the  disease,  the  symptoms  are 
rarely  so  appalling,  as  in  the  first,  though  of  the  same  general 
character.     The  disease  is  less  marked,  and  we  consequently, 
have  a  more  open  enemy  to  deal  with.      In  this  condition  we 
almost  exclusively  rely  upon  blood-letting  to  make  a  first  and 
favourable  impression;  and  there  are  few  who  have  not  witnessed 
with  what  promptitude,  and  success,  this  is  sometimes  effected. 
The  bleeding  to  be  successful,  must  be  carried  to  a  sufficient  ex- 
tent; that  is,  until  it  makes  a  decided  impression  upon  the  pulse; 
or  until  it  flutter  under  the  finger,  or  a  disposition  to  syncope 
discover  itself. 

1399.  Some  have  advised  that  the  blood  should  be  drawn  from 
the  jugular  vein;   there  may  be  an  advantage  in  this,  that  our 
present  experience  does  not  recognise;  certain  it  is,  we  should 
not  hesitate  to  select  this  part,  were  we  left  entirely  to  ourselves, 
since  its  nearness  to  the  diseased  parts,  would  lead  to  the  belief, 
that  they  might  more  certainly  and  speedily  be  relieved  by  it. 
But  to  make  choice  of  this  vein  as  a  general  rule  to  bleed  from, 
we  should  have  much  prejudice  to  contend  with  ;  more  perhaps 
than  the  selection  is  really  worth — but  at  the  same  time  we  would 
recommend  that  this  part  should  not  be  lost  sight  of,  in  certain 
ferocious  cases,  where  life  may  depend  upon  the  difference  of 


CYffANCHE    TRACHEALIS,    OR   CROU*.  415 

influence,  that  the  bleeding  from  one  part  rather  than  from  an- 
other, may  produce. 

1400.  The  repetition  of  the  bleeding,  must  be  governed  by 
circumstances;  for  bleed  we  must  in  some  cases,  again  and  again, 
if  the  system  reacts  with  force,  and  the  pulse  be  found  of  diffi- 
cult reduction.     But  here  we  would  wish  to  caution  the  inexpe- 
rienced practitioner,  against  making  the  difficulty  of  breathing 
the  only  indication  for  more  blood-letting ;  this  should  constitute 
but  one  of  the  considerations;  for  of  itself,  it  is  not  always  suf- 
ficient, especially  in  rapid  cases,  or  in  one,  in  which  the  first 
stage  of  the  disease  was  altogether  neglected,  and  the  commence- 
ment of  the  second,  but  feebly  treated. 

1401.  To  make  a  second  bleeding  proper,  there  must  be  a 
continuation  of*  the  same  symptoms,  though  perhaps  with  a  lesser 
degree  of  force,  which  made  us  determine  upon  this  operation 
in  the  first  instance;  that  is,  the  pulse  must  be- firm,  the  skin 
warm,  the  face  flushed  and  the  oppression  considerable. 

1402.  If  these  conditions  obtain,  we  should  not  hesitate  a  mo- 
ment to  draw  more  blood ;  and  that  to  an  extent  that  shall  pro- 
duce an  evident  alteration  in  the  force  of  the  pulse;  but  two 
bleedings  are  not  to  follow  each  other,  without  the  interval  being 
employed  in  the  exhibition  of  other  remedies;  and  among  the 
first  of  these,  are  the  emetics,  and  the  expectorants,  as  has  been 
already  advised,  together  with  the  use  of  calomel.     In  this  state 
of  the  disease,  as  in  the  one  just  considered,  the  emetic  should 
be  followed  by  the  hive  syrup,  so  as  to  maintain  a  slight  nau- 
seating influence,  as  well  as  occasionally  to  provoke  the  stomach 
to  puking. 

1403.  The  rubefacient  remedies  should  now  succeed  the  ope- 
ration of  the  emetic;  and  such  a  quantity  of  calomel  should  be 
administered,  either  with  the  tartrite  of  antimony,  or  alone,  as 
already  suggested  as  to  procure  a  free  discharge  from  the  bowels. 

1404.  The  greater  the  disposition  the  disease  has  to  run  a 
rapid  course,  or  in  other  words,  the  more  sudden  and  violent 
the  attack,  the  greater  as  a  general  rule,  will  be  the  chance  of 
success,  from  the  use  of  proper  remedies,  and  especialty,  that  of 
blood-letting;  for  it  almost  always  happens,  that  the  slower  cases 
are  attended  by  an  indolent  inflammation,  or  an  engorgement, 
that  will  not  so  well  bear  the  loss  of  blood;  or  will  certainly 
profit  less  by  the  loss  of  it. 

1405.  When  the  practitioner  may  be  reluctant  to  draw  more 
blood  from  the  general  system,  and  yet  believes  the  inflamma- 
tion cannot  be  subdued  without  further  depletion,  he  generally 
has  recourse  to  local  bleeding — hence  the  frequency  of  leeching, 
and  cupping,  in  croup. 

1406.  This  practice  is  recommended  by  almost  every  practi- 


416  CTNANCHE  TRACHEALIS,  OR  CROUP- 

tioner ;  and  by  some  of  very  high  authority;  it  may  therefore  not 
only  excite  surprise,  but  perhaps  draw  upon  us  reprehension, 
when  we  enter  our  protest  against  it;  and  especially  against 
leeching. 

1407.  We  are  free  to  admit,  that  it  appears  every  way  plausi- 
ble, that  drawing  blood  from  near  the  inflamed  part,  should  be 
attended  with  more  success,  than  when  it  shall  be  taken  from  a 
part  more  remote ;  yet  in  the  particular  instance  we  are  consi- 
dering, our  experience  gives  a  uniform  contradiction  to  the  hope 
of  benefit  from  the  practice,  though  it  does  not  impair  perhaps 
the  truth  of  the  general  position.   But  this  failure  of  benefit  from 
local  bleeding,  in  the  case  under  consideration,  must  not  be  con- 
sidered, however,  even  as  an  exception  to  the  general  rules,  just 
mentioned,  but  as  depending  in  a  great  measure,  or  perhaps  alto- 
gether,  on  circumstances,   inseparable  from   the  operation  of 
leeching  itself. 

1408.  The  operation  of  leeching  is  attended  with  several  cir- 
cumstances decidedly  adverse  to  this  disease:  for  1.  It  employs 
considerable  time ;  during  which  the  patient  is  obliged  to  main- 
tain an  irksome  position,  and  this  may  be  extremely  unfavourable 
to  his  breathing.     2.  It  often  becomes  important,  that  the  quan- 
tity of  blood  to  be  drawn,  should  be  exactly  determined :  this 
cannot  be  done  in  leeching — especially,  as  the  after-bleeding  is 
sometimes  very  considerable,  to  the  manifest  injury  of  the  patient, 
in  spite  of  every  attempt  to  arrest  it.    3.  Their  coldness,  and  the 
sudden  exposure  of  the  throat,  after  having  been  warmly  covered, 
is  sometimes  so  mischievous,  that  the  symptoms  can  be  seen  to 
increase  during  the  operation ;  and  are  almost  sure  to  follow  im- 
mediately after  it.     We  can  most  safely  declare,  we  never  have 
in  a  single  instance  witnessed  leeching  do  good ;  but  we  have,  in 
a  number  of  cases,  known  it  to  do  harm. 

1409.  If  topical  bleeding  must  be  had  recourse  to,  let  it  be  by 
cups — against  these  the  objections  are  not  so  strong.  And  if  they 
be  employed,  between  the  shoulders,  is  the  place  to  be  selected; 
when  drawn  from  here,  we  have  seen  it  useful.     Cups  should 
never  be  applied  over  the  throat,  for  reasons  sufficiently  obvious. 

1410.  Dr.  Cheyne  says,  "when  bleeding  is  used  upon  the 
commencement  of  the  violent  symptoms,  the  relief  is  often  im- 
mediate; and  I  have  scarcely  believed  that  I  saw  the  same  child 
breathing  softly,  who  ten  minutes  before  lay  gasping  and  con- 
vulsed." p.  17. 

1411.  We  have  .never  had  the  good  fortune  to  see  this  sudden 
good  effect  from  bleeding  in  genuine  croup;  we  have  a  number 
of  times  witnessed  very  prompt  relief  from  this  remedy,  in  the 
spurious,  or  that  kind  which  is  accompanied  with  sore  throat,  or 
perhaps  bronchitis.     For  the  vessels  of  the  fauces  and  bronchia, 


C1TNANCHE    TRACHEALIS,   OR   CROUP.  417 

seem  to  feel  the  influence  of  venesection  more  certainly  and 
speedily,  than  those  of  the  mucous  membrane  of  the  trachea. 

1412.  Neither  in  the  stage  of  the  disease  now  under  considera- 
tion, nor  in  either  of  the  other  two,  have  we  ever  witnessed  any 
advantage  from  severe  purging;*  though  there  is  evident  use,  in 
having  the  bowels  freely  opened.   Indeed,  in  the  congestive  stage, 
we  think  we  have  constantly  found  it  injurious ;  for  it  rapidly 
diminishes  the  strength,  without  weakening  the  disease.     For 
it  would  seem,  there  is  less  intercommunion  between  the  bowels, 
and  the  respiratory  viscera,  than  with  almost  any  other  part  of 
the  body. 

1413.  Puking  in  this  stage,  (the  second,)  is  manifestly  useful; 
especially,  when  considerable  nausea  accompanies  the  operation; 
it  must  therefore  be  repeated  as  often  as  the  breathing  seems  to 
be  obstructed,  by  accumulating  phlegm.    We  believe  the  tartrite 
of  antimony  to  be  the  best  emetic  in  this  stage  of  the  disease.! 
The  sulphate  of  copper  has  been  much  extolled  lately;  with  what 
propriety,  we  cannot  say  from  our  own  experience. 

1414.  Blisters  are  highly  recommended  by  some;  as  regards 
our  own  experience,  we  are  by  no  means  convinced  of  their 
utility,  unless  it  may  be  in  the  forming  stage  of  this  complaint, 
and  at  the  termination  of  the  second;  but  even  then,  we  are  not 
in  the  habit  of  relying  on  them.     We  prefer  the  rubefacients;  as 
their  powers  are  more  at  command,  and  can  be  renewed  when- 
ever they  have  ceased  to  maintain  a  proper  degree  of  irritation. 
It  has  appeared  to  us,  there  is  a  period  of  this  disease  in  which 
blisters  may  be  useful;  but  they  are  not  exclusively  to  be  relied 
on,  as  just  stated;  we  have  occasionally  employed  them  at  this 
time,  and  once  or  twice  with  marked  advantage.     It  is  when 
the  second  stage  is  merging  into  the  third.  At  this  time  in  some 
few  instances,  they  seem  to  act  with  peculiar  felicity. 

1415.  "The  warm  bath  is  a  very  unequivocal  remedy;  but 
as  it  is  a  simple  and  popular  one,  it  is  generally  used  along  with 
an  emetic,  before  the  physician  is  called;  and  together  or  sepa- 
rately, by  their  antiphlogistic  powers,  they  in  very  many  in- 
stances prevent  the  formation  of  the  disease.  "J 

1416.  There  is  no  remedy  in  this  disease  so  popular,  or  so 
mucli  abused,  as  the  warm  bath — it  is  one  however  that  we  feel 
more  difficulty  in  prescribing,  than  any  other  of  the  materia 

*  May  this  not  be  accounted  for,  from  the  strong  sympathy  which  exists  be- 
tween every  portion  of  mucous  membrane?  And  if  the  extensive  surface  of  it 
which  lines  the  intestines  be  much  irritated  by  drastic  cathartics,  may  it  not 
exert  an  unfriendly  influence  upon  that  of  the  trachea? 

\  Of  late  we  have  questioned  this  assertion — we  think  the  compound  syrup 
of  squills,  at  least  equal,  if  not  superior  to  it.  See  par.  1395. 

t  Cheyne,  p.  25. 

53 


418  CYNANCHE  TRACHEALIS,  OK  CROUP. 

medica;  for  it  seems  to  us  to  be  more  uncertain,  and  varied  in 
its  effects,  than  any  other.  Nor  is  this  to  be  wondered  at ;  since, 
the  temperature  is  never  exactly  fixed,  and  each  given  tempera- 
ture must  be  a  new  remedy;  or  at  least  a  remedy  with  a  different 
power.  Again,  the  state  of  the  nervous  and  arterial  systems, 
must  be  constantly  varying;  therefore  the  effects  of  this  remedy, 
must  necessarily  be  governed  in  a  degree  by  these  conditions. 
The  state  of  the  cutaneous  or  capillary  system,  must  also  vary 
as  to  susceptibility;  therefore  temperature  must  have  different 
operations  upon  it;  these  differences  must  of  course  lead  to  very 
different  results;  and. this  we  have  so  uniformly  found  to  be  the 
case,  that  we  never  prescribe  this  remedy,  but  with  all  the  un- 
certainty which  must  necessarily  attend  applications  empirically 
made. 

1417.  But  we  cannot  agree  with  Dr.  Cheyne,  if  in  calling  the 
warm  bath  a  "simple  remedy,"  he  mean  that  it  is  one  without 
any  decided  powers;  we  look  upon  it  as  one  of  extensive  influ- 
ence; and  may,  therefore,  be  easily  abused,  if  not  judiciously 
directed;  as  it  has  unfortunately  become  a  domestic  remedy. 
Besides,  let  us  call  to  mind  the  importance  of  the  surface  on 
which  this  remedy  is  to  act;  either  as  regards  its  own  functions, 
or  the  parts  which  so  powerfully  sympathize  with  it;  and  we 
shall  find  there  is  no  good  ground  to  consider  this  remedy  as  a 
"simple"  one;  at  least,  not  agreeably  to  our  definition  of  a  sim- 
ple remedy. 

1418.  This,  of  all  the  remedies  employed  in  croup,  requires 
the  most  judgment  in  prescribing  it;  and  certainly  the  most  cau- 
tion, to  apply  it  properly.    We  have  never  seen  it  managed  with 
so  much  address,  as  not  to  have  made  us  tremble  for  the  conse- 
quences ;  nor  with  so  much  success,  as  to  tempt  us  to  brave  them. 
We  can  most  conscientiously  declare,  we  have  never,  in  a  single 
instance,  witnessed  a  decided  advantage  to  arise  from  its  appli- 
cation ;  but  we  can  most  truly  say,  we  have  had  the  most  un- 
equivocal evidence  of  injury.     We  therefore  never  prescribe  it 
in  this  disease. 

1419.  Do  not  let  us  be  understood  to  condemn  this  remedy, 
when  employed  by  others,  because  we  do  not  ourselves  under- 
stand its  management;  we  only  mean  to  confess  our  ignorance 
of  the  proper  state,  or  time,  for  its  application.     We  are  afraid 
that  this  remedy  has  become  too  much  a  part  of  routine  in  this 
complaint;  therefore,  very  likely  to  be  abused.   There  is  a  popu- 
lar feeling  in  its  favour  which  we  are  very  certain  it  does  not 
deserve;  and, in  consequence,  it  becomes  "a domestic  remedy," 
and  "is  employed  before  the  physician  sees  the  patient,"  and 
that  we  fear  to  the  injury  of  the  individual  who  is  subjected 
to  it. 


CYNANCHE  TRACHEALIS,  OR  CROUP.          419 

1420.  Laudanum  in  combination  with  antimony,  is  recom- 
mended by  Dr.  Cheyne,  when  the  febrile  symptoms  run  high — 
we  admit  this  to  be  high  authority  for  the  practice;  but  unless 
we  witness  more  success  from  this  combination  in  the  hands  of 
others,  than  has  been  experienced  by  ourselves,  we  shall  not 
again  be  tempted  to  employ  it.    Laudanum,  as  far  as  our  experi- 
ence goes,  has  ever  been  injurious  in  this  stage. 

1421.  If  the  disease  does  not  yield  pretty  early  after  the  for- 
mation of  the  second  stage,  to  the  remedies  just  pointed  out,  the 
vessels  of  the  inflamed  surface  relieve  themselves  by  effusion, 
and  thus  form 

The  Third  Stage. 

1422.  This  stage  consists  in  the  formation  of  a  deciduous  mem- 
brane, which,  more  or  less,  strictly  fills  the  trachea,  or  else,  in  the 
pouring  out  of  a  quantity  of  purulent  lymph,  which  does  not 
coagulate;  butalmost  as  certainly  obstructs  the  air-passages.   This 
effusion  is  not  confined,  however,  in  all  instances  to  the  trachea; 
the  bronchial  vessels  relieve  themselves  in  the  same  manner;  and 
this  sometimes  throughout  the  lungs;  as  far  at  least  as  the  naked 
eye  can  trace  them. 

1423.  It  is  of  much  consequence  to  recollect  this  highly  im- 
portant pathological  truth  ;  since  it  will  have  a  strong  bearing  on 
the  question  of  an  operation,  whenever  this  may  be  agitated. 

1424.  The  third  stage  necessarily  is  one  of  great  hopelessness; 
since  we  cannot  with  certainty  get  rid  of  the  existing  obstruc- 
tion; or  if  we  could,  we  cannot  alter,  or  at  least  but  very  rarely, 
the  disposition  of  the  parts,  to  perpetuate  the  difficulty  by  new 
productions. 

1425.  The  indications  in  this  stage  are,  1st,  to  remove  the  ob- 
structing lymph  from  the  windpipe;  and  2d,  to  prevent  the  for- 
mation of  more,  by  altering  the  condition  of  the  inflamed  surface 
of  the  trachea. 

1426.  In  some  few  instances,  emetics  have  fulfilled,  both  the 
one  and  the  other  indication  ;  and  the  patient  has  been  thus  most 
unexpectedly  snatched  from  the  grave.* 

1427.  The  membrane  has  been  more  frequently  removed  from 
the  trachea,  than  its  removal  has  been  attended  by  success  to  the 
patient,  after  its  discharge.     This  is  a  most  melancholy  truth, 

*  "  I  shall  here  notice  only  those  remedies  which  have  been  found  decidedly 
beneficial.  Of  this  kind  are  emetics  repeated  daily  or  even  twice  a  day.  They 
evidently  accelerate  the  separation  of  the  adventitious  membrane,  and  favour 
its  expulsion.  However  valuable  this  treatment  may  be,  and  I  have  myself 
obtained  cures  which  I  could  attribute  to  it  alone,  it  is  no  doubt  too  true,  that 
the  greater  number  of  cases  still  prove  fatal."  Laennec,  p.  126. 


420          CTNANCHE  TRACHEALIS,  OR  CROUP. 

and  one  that  should  not  be  lost  sight  of;  especially,  as  on  the  re- 
moval of  the  membrane  recovery  is  so  confidently  expected. 
Never  shall  we  forget  our  feelings,  when  this  took  place  in  a 
beloved  child  of  our  own ;  nor  ever  cease  to  remember  our  dis- 
appointment, when  we  found  it  to  be  unavailing. 

1428.  Michaelis,  (Cheyne,  Case  X.  p.  65,)  relates  a  case  of 
death  after  the  membrane  was  twice  discharged  by  emetics ;  nor 
is  this  surprising,  since  by  the  removal  of  the  obstruction,  we  do 
not  remove  the  disposition  to  subsequent  effusion ;  and  as  long  as 
this  continues,  there  can  be  no  security  against  new  formations. 

1429.  But  this  is  not  to  make  us  abandon  an  enterprise  in 
which  so  much  may  be  gained,  if  we  succeed  in  removing  the 
obstructing  membrane;  especially  as  the  same  author  furnishes 
us  with  an  instance  of  success,  after  the  membrane  has  been 
thrown  up. 

1430.  As  in  the  third  stage,  the  obstruction  is  purely  mecha- 
nical so  far  as  we  know;  and  as  that  consists  of  a  membranous 
production,  but  feebly  attached  to  the  side  of  the  trachea,  as  fresh 
lymph  is  most  probably  constantly  pouring  out,  to  weaken  its 
adhesion,  it  would  seem  that,  that  remedy  which  would  give  the 
most  sudden  shock  to  the  respiratory  organs,  would  bid  fairest, 
to  remove  it — hence  the  utility  of  pretty  powerful  emetics  at 
this  period. 

1431.  In  this  all  practitioners  seem  to  agree ;  but  there  is  some 
variety  of  opinion,  on  the  proper  substance  for  this  purpose.  In 
Europe,  saline,  or  antimonial  emetics,  are  considered  best;  in 
this  country  the  polygala  seneka  in  very  strong  decoction  is  pre- 
ferred; and  we  believe  with  propriety.     At  least  the  only  in- 
stance we  have  witnessed  of  the  expulsion  of  the  membrane,  was 
produced  by  a  very  strong  decoction  of  this  root.* 

1432.  We  would  therefore  rely  on  it  with  more  confidence 
than  any  other  of  the  emetic  substances. 

1433.  This  medicine  is,  however,  apt  to  run  off  by  the  bowels 
when  exhibited  thus  strong ;  should  this  be  the  case,  a  quantity 
of  laudanum  sufficient  to  merely  restrain  its  purgative  effects, 
should  be  given  from  time  to  time.     Two  or  three  drops  every 
two  or  three  hours,  will  generally  be  found  sufficient  for  this 
purpose. 

1434.  We  have  but  very  little  confidence  in  any  other  reme- 

*  Take  half  an  ounce  of  powdered  seneka,  pour  on  it  half  a  pint  of  boiling 
water,  and  let  it  simmer  until  nearly  half  reduced;  strain  it  carefully,  and  give 
a  tea-spoonful  every  fifteen  or  twenty  minutes  until  it  puke.  This  quantity 
will  answer  for  a  child  from  one  to  three  years  old — for  one  of  greater  age, 
two  tea-spoonfuls  at  a  time  may  be  given;  but  we  believe  the  decoction  should 
never  be  weaker  than  the  above. 


CYNANCHE  TRACHEALIS,  OR  CROUP.          421 

dies  in  this  stage  of  the  disease ;  especially  any  that  can  fulfil  the 
second  indication,  unless  emetics  do. 

1435.  We  have  never  seen  calomel,  blisters,  or  warm  bath, 
do  the  least  good  at  this  period ;  indeed  the  painful  remedies 
should  now,  we  think,  be  withheld,  (if  we  except  the  more 
powerful  rubefacients,)  since  they  hold  out  so  little  promise  of 
success.     We  thought  we  saw  evident  relief  in  a  late  case,  from 
the  spirit  of  turpentine.*  Twenty  drops  were  given  every  hour; 
it  seemed  to  relieve  much ;  but  the  patient  died. 

1436.  As  a  last  resource,  tracheotomy  has  been  proposed  with 
confidence ;  but  it  has  been  but  too  often  performed  without  suc- 
cess.   Nor  is  this  to  surprise  us ;  since  by  the  operation  nothing 
more  can  be  expected,  than  has  resulted  from  the  spontaneous 
discharge  of  the  membrane ;  and  we  have  already  said  that  this 
is  but  rarely  followed  by  permanent  relief. 

1437.  In  our  opinion,  the  operation  has  been  proposed  with 
more  intrepidity,  than  discretion ;  for  until  we  can  prevent  new 
accumulations  after  the  removal  of  the  previous  ones,  we  need 
promise  ourselves  but  little  success  from  this  scheme.     It  has 
been  said,  that  the  failure  from  this  operation  has  been  princi- 
pally owing  to  its  being  performed  too  late ;  and  hence  it  has 
been  advised  early  in  the  disease.    But  who  would  promise  him- 
self that  he  had  saved  life  by  this  operation,  should  the  patient 
even  live,  since  if  it  be  performed  early,  other  remedies  might 
have  succeeded  as  well  ?    And  when  performed  late,  who  has 
witnessed  its  success  ?    Therefore,  in  the  early  stage  of  the  dis- 
ease, the  operation  is  certainly  not  called  for,  nor  would  it  be 
proper  to  have  recourse  to  it,  since,  the  disease  is  very  often  re- 
lieved without  it,  and  in  the  latter,  we  believe  it  has  ever  been, 
unavailing. 

1438.  We  have  seen  it  performed  twice  without  success, 
where  the  operation,  simply  considered,  had  every  advantage 
which  sound  judgment,  and  consummate  skill  could  give  it — for 
Dr.  Physick  was  the  operator.    And  we  believe  we  do  not  ven- 
ture too  much,  when  we  say  he  has  no  confidence  in  it.     Dr. 
Cheyne  employs  some  most  convincing  arguments  against  this 
operation,  to  which  we  with  pleasure  refer  those  who  may  wish 
to  investigate  this  subject  further.! 

*  What  might  be  the  effects  of  this  medicine  in  the  congestive  stage  of 
croup,  if  boldly  pushed,  we  have  yet  to  learn;  we  think,  however,  it  deserves 
a  trial,  as  its  influence  upon  the  mucous  membranes  seems  to  be  undisputed; 
we  shall  certainly  urge  it,  the  first  fair  opportunity  we  have  the  misfortune  to 
contend  with. 

f  We  are  disposed  to  believe,  that  the  cases  in  which  the  operation  of  tra- 
cheotomy was  performed  with  success,  were  instances  of  Cynanche  laryngea; 
for  in  this  disease,  the  patient  is  suffocated  from  an  cedematous  swelling  of  the 
glottis  taking  place  very  rapidly  from  the  inflammation  of  the  larynx,  which 


422  CYNANCHE    PAROTID^A,    OR   MUMPS. 

1439:  But  notwithstanding  the  unmanageable  character  of 
this  disease,  when  its  first  stages  has  been  neglected,  or  feebly 
treated,  we  have  the  experience  of  some  of  the  most  respectable 
European  practitioners,  as  well  as  our  own,  to  bear  us~out  in  the 
assertion,  that  when  early  attacked,  by  adequate  means,  there 
are  few  diseases  so  entirely  under  the  controul  of  medicine. 

SECT.  IV. — CYNANCHE  PAROTIDS  A,  OR  MUMPS. 

1440.  This  disease  consists  in  an  inflammation  of  the  parotid 
glands,  and  is  of  the  phlegmonous  kind.     It  is  often  confined  to 
one  side,  though  more  generally  to  both ;  sometimes,  the  maxil- 
lary glands  are  also  implicated,  and  hence  the  swelling  of  the 
jaws. 

1441.  For  the  most  part,  this  is  a  disease  of  little  moment; 
especially  if  it  occur  in  the  warmer  seasons  of  the  year.     But  at 
other  times,  there  is  much  constitutional  disturbance.     Rigours 
followed  by  much  fever,  sometimes  happen,  especially  during 
the  variable  weather  of  early  spring,  or  late.  fall.     The  first  sen- 
sation of  inconvenience,  is  about  the  angle  of  the  lower  jaw  ;  this 
part  presently  becomes  painful  upon  moving  the  head ;  tumour 
is  now  perceived  at  this  part,  which  goes  on  to  increase  until 
the  fourth  or  fifth  day;  after  which  it  gradually  subsides,  if  not 
maintained  by  fever.     It  is  not  unusual  for  one  side  to  be  first 
affected  ;  and  after  this  has  nearly  run  its  course,  the  gland  upon 
the  opposite  lakes  on  inflammation,  and  also  runs  its  course. 
When  this  happens,  the  disease  becomes  more  protracted  and 
painful. 

1442.  We  have  occasionally  seen  severe  suffering  from  this 
complaint ;  this  was  in  consequence  of  a  high  degree  of  inflamma- 
tion and  an  excessive  enlargement  of  the  gland.     The  jaws  be- 
come closed,  and  deglutition  is  performed  with  much  difficulty. 
The  ears  are  now  and  then  much  pained,  as  in  common  ear-ache. 
The  stomach  is  sometimes  annoyed  by  nausea,  or  is  disturbed 
by  vomiting;  and  in  some  few  instances,  we  have  witnessed  ex- 
cessive fever,  and  even  delirium. 

1443.  When  this  complaint  is  unattended  by  much  fever,  its 
progress  is  regular,  and  its  termination  favourable — in  such  case, 
it  is  scarcely  an  object  of  medical  discipline;  at  most  it  requires 
but  lenient  purging,  a  low  diet,  and  some  mild  topical  applica- 
tions, as  warm  sweet  oil,  or  hog's  lard,  and  the  pained  parts 
kept  warm  by  flannel.     Care  however  should  always  be  taken, 
even  in  the  mildest  forms  of  this  disease,  that  the  patient  be  not 

may  again  pretty  quickly  subside,  if  respiration  can  be  maintained  a  sufficient 
time,  and  which  seems  to  be  insured  by  the  artificial  means  resorted  to  in  this 
operation. 


CTNANCHE    PAROTIDJ3A,    OR   MUMPS.  423 

exposed  to  the  risk  of  taking  cold;  as  a  remarkable  peculiarity 
attends  this  complaint ;  which  is  its  disposition  to  metastasis  or 
translation;  to  the  testes,  in  males;  and  to  the  breasts,  in  fe- 
males, especially  in  adults. 

1444.  In  the  severer  forms  however  of  this  complaint,  active 
measures  are  sometimes  indispensable ;  bleeding  to  a  considera- 
ble extent,  we  have  occasionally  found  necessary  ;  brisk  purging, 
and  the  strict  observance  of  an  antiphlogistic  regimen. 

1445.  Occasionally  we  have  been  obliged  to  have  recourse  to 
topical  depletion  by  leeches ;  and  this  followed  by  warm  cata- 
plasms of  bread  and  milk,  to  promote  the  further  discharge  from 
the  bites  of  these  animals.     The  mercurial  purges  appear  to  an- 
swer best  in  this  disease;  especially  if  their  operations  are  pro- 
moted by  either  of  the  neutral  salts. 

1446.  Should  a  translation  take  place,  it  may  be  accompanied 
by  many  distressing  symptoms.     In  the  male,  we  once  saw  the 
testes  prodigiously  enlarged ;  much  suffering  was  endured,  and 
great  hazard  was  incurred  by  the  change.     Violent  fever  and 
delirium  accompanied  this  metastasis;  and  it  required  a  perse- 
verance in  very  active  remedies,  to  subdue  them. 

1447.  In  the  female,  the  breasts  are  the  seats  of  the  metasta- 
sis; they  sometimes  enlarge  very  much,  and  become  extremely 
tender  and  painful ;  but  we  believe  they  never  run  on  to  suppu- 
ration. 

1448.  In  the  treatment  of  this  complaint  under  a  change  of 
seat,  regard  should  always  be  paid  to  the  part  originally  affected. 
With  this  view  we  have  always  blistered  the  parts  immediately 
over  the  parotids,  and  we  think  with  decided  advantage.    If  the 
change  has  taken  place  in  the  male,  we  also  exhibit  an  emetic, 
and  apply  warm  vinegar  by  means  of  flannel  to  the  scrotum,  and 
this  to  be  repeated  from  time  to  time.     A  brisk  purging  should 
also  be  instantly  instituted,  after  the  operation  of  the  emetic  is 
entirely  over;  provided  neither  the  blistering  nor  the  vomiting 
has  been  successful  in  recalling  the  morbid  action  to  the  original 
seat  of  the  disease. 

1449.  In  females,  besides  blistering  and  purging,  (for  witn 
them  it  is  doubtful  whether  emetics  are  useful  in  this  condition,) 
we  apply  warm,  vinegar  by  means  of  flannels  to  the  inflamed 
breasts,  as  directed  above.     We  have  never  seen  any  permanent 
evil  follow  these  translations,  though  several  such  are  recorded 
by  authors. 

1450.  This  dease,  like  several  others,  affects  the  system  but 
once ;  it  is  supposed  to  be  contagious ;  but  whether  this  be  well 
founded  we  are  not  prepared  to  say — it  is  almost  always  epide- 
mic, at  least  in  this  country;  which  may  with  much  propriety 
call  in  question  its  contagious  nature. 


424  PERTUSSIS,    OR    HOOPING-COUGH. 


SECT.  V. — PERTUSSIS,  OR  HOOPING-COUGH. 

1451.  Hooping-cough  usually  begins  like  a  cold,  with  more  or 
less  fever,  and  catarrhal  defluxion ;  these  continue,  in  some  in- 
stances, throughout  every  stage  of  the  complaint ;  while  in  others 
they  cease  in  a  few  days.     The  onset  of  this  disease  is  for  the 
most  part  abrupt,  without  any  distinct  febrile  movement;  and 
is  sometimes  early  attended  with  the  peculiar  inspiration  which 
gives  it  its  common  name. 

1452.  But  this  mark  must  not  be  too  exclusively  relied  upon, 
in  the  history  of  this  complaint ;  for  we  have  repeatedly  seen 
cases  of  hooping-cough  where  the  sonorous  inspiration  has  been 
altogether  wanting — we  are  certain  we  do  not  labour  under  any 
mistake  on  this  subject,  as  we  have  witnessed  the  fact  in  the 
same  family  of  children,  all  of  whom  were,  at  one  and  the  same 
time,  under  the  influence  of  this  disease.    Dr.  Hastings  declares 
the  same  fact;  he  says,   "in  some  cases,  where  it,  (hooping- 
cough,)  has  obviously  arisen  from  contagion,  and  has  begun  in 
the  form  of  catarrh,  it  never  takes  on  the  peculiar  character  of 
hooping-cough ;  for  the  difficulty  of  breathing,  cough,  and  py- 
rexia,  are  so  urgent  as  to  prove  speedily  fatal."*    It  would  seem 
that  the  absence  of  hooping  has  been  a  fatal  symptom  in  the 
cases  observed  by  Dr.  H.  but  we  do  not  think  this  to  be  essen- 
tial to  this  exemption ;  for  it  is  certain,  that  death  does  not 
always  follow  in  such  instances,  if  our  observations  do  not  very 
much  mislead  us. 

1453.  At  other  times  a  considerable  period  elapses  before' this 
takes  place,  and  in  some  cases  it  does  not  at  all  happen.    Cullen 
tells  us  he  has  had  instances  of  a  disease,  "  which  though  evi- 
dently arising  from  the  chincough  contagion,  never  put  on  any 
other  form  than  that  of  common  catarrh." 

1454.  The  disease  becoming  confirmed,  the  paroxysm  con- 
sists of  a  mjmber  of  short  expirations,  closely  following  each 
other,  so  as  to  produce  a  sense   of  suffocation,  to   overcome 
which,  a  violent  effort  of  coughing  is  made,  which  usually  ends 
in  vomiting,  or  with  a  discharge  of  phlegm,  or  mucus,  from  the 
lungs. 

1455.  In  many  cases,  when  the  paroxysm  is  over,  there  is 
complete  relief  for  the  time  being;  so  much  so,  that  the  indivi- 
dual seems  not  at  all  affected,  except  perhaps,  temporarily  a  lit- 
tle weakened. 

1456.  This  complaint  is  not   accompanied  by  difficulty  of 
breathing,  as  a  necessary  attendant,  unless  in  such  as  may  have 

*  Treatise  on  the  Inflammation  of  the  Mucous  Membrane  of  the  Lungs,  p. 
200. 


PERTUSSIS,    OR    HOOPING-COUGH.  425 

0 

a  chronic  affection  of  the  thoracic  viscera.  If  it  attend  hooping- 
cough  in  such  as  have  no  pectoral  complaint  ordinarily,  it  be- 
trays for  the  most  part,  some  latent  mischief  in  either  the  bron- 
chial membrane,  or  the  substance  of  the  lungs  themselves — this 
may  be  inflammation  or  engorgement. 

1457.  Dr.  Watt  says  that  hooping-cough  is  sometimes  attended 
with  great  torpor  of  the  bowels,  requiring  large  and  frequent 
doses  of  medicine  before  it  can  be  overcome ;  we  have  never 
witnessed  this  condition ;  and  when  it  does   occur,  it  is  per- 
haps only   "a  relative  state;"  the  coats  of  the  stomach  and 
bowels  being  "varnished"  as  it  were  with  mucus,   and  this 
preventing  the  operation  of  medicine,  by  not  permitting  a  con- 
tact between  the  medicine,  and  the  intestinal  membrane.     Also 
that  the  urinary  secretions  is  influenced,  and  micturation  pro- 
duced. 

1458.  In  the  commencement,  expectoration  is  sometimes  very 
deficient ;  the  cough  is  hard  and  dry ;  the  paroxysms  recur  fre- 
quently, and  are  long-continued.     Congestion  of  the  lungs  now 
take  place;  which  produce,  by  the  interruption  of  the  circulation 
in  these  organs,  a  correspondent  state  of  the  head ;  and  as  a  con- 
sequence, a  turgescency  and  suffusion  of  face,  amounting  occa- 
sionally even  to  lividness,  which  is  sometimes  relieved  by  gushes 
of  blood,  from  the  mouth,  nose,  eyes,  or  ears.     In  this  manner, 
the  disease  runs  an  indefinite  course,  from  one  month  to  three, 
or  even  twelve  months,  though  the  average  is,  perhaps,  the  se- 
cond period.    This,  however,  very  much  depends  on  the  season 
of  the  year;  it  being  always  of  longer  duration  in  winter.     The 
popular  notion  is,  and  which  indeed  is  not  far  from  the  fact, 
that  it  is  six  weeks  in  reaching  its  height,  continuing  for  some 
time  with  but  little  abatement,  then  declines,  and  goes  off  in  six 
weeks  more.* 

1459.  Some  writers,  especially  Webster,  consider  the  hoop- 
ing-cough as  consisting  in  some  cerebral  disorder;  and  adduce 
as  evidence,  the  existence  of  head-ache,  redness  in  the  eyes  and 
cheeks,  and  the  relief  that  a  bleeding  at  the  nose  affords,  together 
with  the  appearance  of  the  brain  and  its  appendages,  after  death.t 

1460.  Dr.  Gregory,  like  Webster,  speaks  of  a  "  tensive  pain 

*  The  course  and  termination  of  hooping-cough  is  very  uncertain;  for  even 
when  mild  as  respects  its  general  symptoms,  it  may  persevere  without  much 
change  from  two  to  four  months;  and  the  severer  forms  may  last  a  year,  as  we 
have  more  than  once  seen.  Weather  has  a  very  decided  influence  upon  its 
character  and  continuance;  being  almost  always  of  a  milder  grade  and  shorter 
duration  in  warm  dry  weather. 

•f-  That  the  nervous  system  is  occasionally  implicated  in  cough  there  can  be 
no  doubt;  but  that  a  pathological  condition  of  any  one  portion,  is  the  cause  of 
hooping-cough,  remains  yet  to  be  proved.  Lobstein  (a)  in  his  account  of  the 

(a)  De  Nervi  Sympathetic!,  p.  150,  §  142.  Tab.  viii.  Fig.  i. 

54 


426  PERTUSSIS,    OR    HOOPING-COUGH. 

of  the  forehead,  and  in  severe  colds,  this  is  obviously  an  urgent 
symptom,  and  one  which  demands  attention  in  reference  to  prac- 
tice." We  have  paid  considerable  attention  ever  since  we  read 
Mr.  Webster's  paper  on  hooping-cough,  to  the  symptoms  which 
particularly  mark  this  disease;  but  we  have  never  satisfied  our- 
selves of  the  existence  of  any  primary  cerebral  disorder.  We 
have  occasionally  had  confessions  from  our  patients  that  they 
had  more  or  less  head-ache,  especially  after  violent  coughing, 
but  there  is  surely  nothing  in  this,  more  than  might  be  expected, 
from  the  severe  efforts  the  chest  demands  in  this  disease.  And  of 
the  "  tensive  pain  in  the  forehead"  just  spoken  of,  we  have  never 
been  able  to  satisfy  ourselves  that  it  existed,  even  late  in  the 
disease.  This  may  have  arisen  from  our  patients,  at  least  nineteen 
out  of  the  twenty  we  have  attempted  to  examine  with  this  view, 
were  too  young  to  either  describe  it,  or  make  them  sensible  of 
our  meaning.  In  the  few  we  interrogated  that  could  comprehend 
what  we  suppose  Mr.  Webster  intended  by  the  expression,  it 
was  certainly  wanting.  Nor  is  the  relief  experienced  from  bleed- 
ing from  the  nose,  any  proof  of  the  existence  of  the  condition  of 
the  brain  and  its  appendages  Mr.  W.  insists  on;  since  this  kind 
of  bleeding  very  certainly  removes  pain  from  the  head,  when 
the  mucous  membrane  of  the  frontal  sinuses  is  inflamed  in  catarrh. 
Besides,  the  appearances  after  death,  as  stated  by  Mr.  Webster, 
do  not  appear  to  be  confirmed  by  Laennec. 

1461.  Dr.  Watt  says,  as  observed  above,  that  this  disease  is 
a  bronchitis.     And  dissection  agreeably  to  him,  has  proved  this 
to  be  the  case.     In  case  third  he  says,  that  "  on  laying  open  the 
upper  part  of  the  trachea  its  internal  surface  was  of  a  reddish 
flocculent  appearance,  but  without  any  inflammatory  exudation. 
This  inflammatory  appearance  increased  as  we  proceeded  down- 
wards, till  in  the  more  minute  ramifications  of  the  bronchia,  the 
whole  surface  was  of  a  bright  red  colour,  as  if  painted. "     Watt 
on  the  chincough,  page  145.     And  Dr.  Lettsom  says,  that  in  a 
dissection  made  by  Mr.  Combe  of  a  patient  who  died  of  hooping- 
cough,  that  the  ramifications  of  the  aspera  arteria  were  greatly 
inflamed,  and  that  the  further  they  were  followed  the  more  con- 
siderable the  inflammation  appeared. 

1462.  While  on  the  other  hand,  Dr.  Watt  says,  page  146, 

sympathetic  and  its  ganglia,  mentions  the  case  of  a  child  of  six  years  old  who 
died  of  a  convulsive  cough,  and  in  which,  the  left  side  of  the  solar  plexus  was 
found  inflamed,  the  right  remaining  sound.  And  Autenrieth  of  Tubengen,  in 
a  similar  case,  found  the  vagus  nerve  inflamed  in  its  whole  course  through  the 
thorax.  The  neurilema  was  painted  with  blood-vessels,  and  the  pulp  had  a 
dull  red  tinge.  The  cardiac  and  sympathetic  nerves  in  the  thorax,  were  also 
in  a  slight  degree  affected.  We  have  therefore  no  doubt,  that  a  pathological 
condition  of  portions  of  the  nervous  system  may  produce  cough,  and  that 
cough  be  convulsive;  but  still,  every  convulsive  cough  is  not  hooping-cough. 


PERTUSSIS,    OR    HOOPING-COUGH.  427 

that  "on  removing  the  skull-cap,  the  dura  mater  adhered  to  it 
very  firmly,  but  did  not  show  any  signs  of  disease.  The  veins 
over  the  surface  of  the  brain  were  very  turgid,  but  perhaps  not 
more  so  than  we  usually  find  in  young  subjects.  There  was  no 
water  in  the  ventricles ;  and  the  other  parts  of  the  brain  appeared 
to  be  perfectly  healthy.  And  other  dissections  mentioned  by 
him  prove,  that  hooping-cough  is  virtually  a  diseased  condition 
of  the  mucous  membrane  of  the  bronchia ;  and  that  the  brain  if 
affected,  is  so  secondarily;  and  consequently,  not  the  seat  of  the 
disease.  Besides,  the  "tensive  pain  in  the  forehead,"  is  a  con- 
stant attendant  upon  "  bronchitis,"  and  must  not  be  looked  upon, 
as  a  necessary  consequence  of  a  cerebral  affection. 

1463.  With  respect  to  the  origin  of  pertussis,  there  is  consi- 
derable doubt.     It  is  supposed  to  depend  on  a  specific  contagion, 
which  affects  persons  only  once.     To  this  however,  there  may 
be  exceptions. 

1464.  While  it  is  pretty  generally  admitted  that  the  disease 
proceeds  from  contagion ;  there  are  writers  who  maintain  that 
it  occasionally,  at  least  prevails  as  an  epidemic ;  and  hence  must 
originate  in  a  more  common  source.    Much  discussion  has  lately 
taken  place  on  this  point:  but  the  facts  are  not  sufficiently  nu- 
merous, nor  well  authenticated,  to  warrant  any  positive  con- 
clusion.    Yet  we  confess,  that  we  are  inclined  to  believe  that  it 
depends  on  causes  of  a  more  general  and  pervading  influence 
than  contagion. 

1465.  That  it  does  in  some  instances  arise  from  other  causes 
than  contagion,  seems  quite  certain.     Willis,  who  was  the  first 
to  describe  it  accurately,  declares  it  to  be  an  epidemic,  occurring 
most  commonly  in  spring  and  autumn.     By  Hoffman  it  is  said 
to  have  spread  in  Berlin  to  a  great  extent  in  the  same  way.     In 
the  tenth  volume  of  the  Medical  Repository  of  New  York,  Dr. 
Willey  gives  an  account  of  the  disease  having  suddenly  broken 
out  in  Block  Island,  and  where  it  prevailed  widely,  without  the 
inhabitants  of  the  place  having  had  any  intercourse  with  an  in- 
fected source.    It  is  a  rule  with  few  or  no  exceptions,  that  where 
a  disease  can  be  traced  to  atmospherical  influence,  it  does  not 
prove  contagious.     Nature,  indeed,  can  hardly  employ  two  such 
opposite  causes  to  produce  the  same  effect.* 

*  It  is  a  well  known  fact,  that  many  become  affected,  where  every  precaution 
is  taken  to  avoid  contagion;  and  that  the  disease  is  uniformly  relieved  or  even 
cured,  by  a  removal  beyond  the  limits  of  the  supposed  distempered  atmosphere. 

Agreeably  to  Desruelles,  the  following  writers  have  described  epidemic 
hooping-cough.  (Traite"  de  la  Coque  cluche,  p.  101.) 

•  Pasquier  speaks  of  an  epidemic  of  this  kind  that  broke  out  in  March,  1411. 
More  than  100,000,  in  Paris  alone,  were  attacked  with  it.  This  account  is 
confirmed  by  Maquay. 

De  Thou  relates  another  epidemic,  that  besieged  Paris,  1510;  this  was  called 


428  PERTUSSIS,    OR    HOOPING-COUGH. 

1466.  Believing  that  the  complaint  is  generated  by  speci- 
fic contagion,  we  have  perhaps  too  much  neglected  to  look  for 
other  causes  of  its   production.*     Yet  on  the  whole,  in   the 
present  state  of  our  knowledge,  it  will  be  most  prudent  to  pro- 
ceed in  practice,  under  the  impression  that  it  is  of  a  contagious 
nature. 

1467.  It  may  be  inferred  from  the  history  of  the  disease,  that 
the  diagnosis  is  neither  difficult  nor  obscure,  but  this  is  not  ex- 
actly so ;  for  in  its  commencement,  it  so  much  resembles  the 
common  catarrh,  that  it  is  almost  always  mistaken  for  it;  espe- 
cially, in  early  spring,  and  late  autumn:  nor  can  it  well  be  de- 
cided, which  disease  it  may  be,  until  the  permanency  and  obsti- 
nacy of  the  affection,  declare  it  to  be  hooping-cough. 

1468.  Dr.  Heberden  says,  that  "old  persons  are  less  liable  to 
hooping-cough  than  children,  but  are  by  no  means  exempt  from 
it ;  I  have  seen  it  in  a  woman  of  seventy,  and  in  a  man  of  eighty. 
A  child  has  some  notice  of  the  approach  of  a  fit,  so  as  to  be  able 
to  run  to  his  nurse  or  mother,  before  it  begins ;  but  adults  are  as 
it  were  overpowered  at  once  upon  the  access  of  the  fit,  so  that 
they  fall  down  instantly  as  in  an  apoplexy,  but  very  soon  come 
to  themselves ;  this  is  a  distinguishing  symptom  of  the  disease 
in  those  who  are  grown  up."t 

1469.  The  remote  cause  of  hooping-cough  may  be  received, 
at  the  moment  catarrh  is  about  to  make  its  appearance ;  and  this 
may  be  confounded  with  it ;  or  it  may  be  called  into  action  by 
the  catarrhal  affection,  and  thus  perpetuate  the  symptoms  of  this 
disease.     Or  it  may,  and  we  believe  it  often  does  at  the  periods 
just  named,  assume  all  the  forms  of  catarrh,  and  from  which,  in 
the  commencement,  it  would  be  impossible  to  decide,  whether 
the  affection  under  consideration  be  hooping-cough  or  catarrh ; 
for  hooping-cough,  in  the  spring  and  fall,  at  its  onset,  is  at- 
tended by  as  much  febrile  action  as  catarrh,  and  it  is  not  until 
this  inflammatory  stage  is  about  to  pass  away,  that  the  cough  as- 
sumes the  paroxysmal  form,  and  declares  the  disease  to  be  hoop- 
ing-cough.   When  the  spring  is  pretty  far  advanced,  and  during 

hooping-cough;  the  symptoms  were  not  related  by  him;  though  mentioned  by 
Sennertus. 

Reverius  mentions  one  that  spread  over  almost  the  whole  of  Europe,  in  1557. 

Buillon  gives  an  account  of  one  in  1578. 

Geller  describes  one  that  took  place  in  1557,  in  the  duchy  of  Mecklenburg. 

Askou,  one  that  happened  at  Copenhagen,  1775. 

Arrand  one  that  occurred  at  Mayence,  in  1769,  &c.  &c. 

From  these  testimonials  it  would  appear,  that  this  disease  has  occasionally 
appeared  in  an  epidemic  form,  from  1411  to  1815;  the  last,  that  is,  the  one  of 
1815,  is  said  to  have  occurred  at  Milan.  * 

*  Dr.  Watt  gives  an  account  of  a  cough,  resembling  in  every  respect  the 
hooping-cough,  produced  by  a  quantity  of  saw-dust  getting  into  the  windpipe. 

f  Commentaries,  p.  434. 


PERTUSSIS,   OR    HOOPING-COUGH.  429 

the  hot  weather  of  summer,  hooping-cough  is  rarely  confounded 
with  catarrh ;  for  at  these  periods  there  will  be  less  fever,  and 
the  disease  will  more  quickly  betray  its  peculiar  character.  But 
fortunately  no  evil  can  arise  from  their  being  confounded ;  for 
at  this  period  their  treatment  must  be  precisely  the  same.  It 
also  resembles  the  initial  symptoms  of  measles;  for  in  hooping- 
cough  there  is  sneezing,  watery  eyes,  swelling  of  the  eyelids, 
and  an  unusual  fulness  of  the  face.  But  the  doubts  to  which  of 
the  diseases  these  symptoms  belong,  is  for  the  most  part  soon 
cleared  up,  by  the  eruption  taking  place  in  measles  on  the  third 
or  fourth  day  after  the  commencement  of  the  catarrhal  affection. 
It  is  however  said  that  instances  of  measles,  have  occurred  with- 
out any  eruption  having  taken  place ;  but  this  we  have  never 
seen. 

1470.  This  disease  is  generally  most  severe  with  infants,  as 
they  cannot  expectorate  with  the  same  freedom  as  older  chil- 
dren, and  are  thus  debarred  this  source  of  relief.     Dr.  Watt  and 
Mr.  Moss,  however,  seem  to  be  of  a  different  opinion.    •  Dr.  W. 
says,  "I  have  almost  always  found  that  a  healthy  child  at  the 
breast,  suffers  as  little  from  the  disease,  as  at  any  age."  p.  71. 
Mr.  M.  declares,  that  "a  child  of  two  or  three  months  old  will 
often  struggle  through  it,  as  safely  as  an  older  child."* 

1471.  Where  it  attacks  with  much  fever  and  catarrh,  it  is 
unfavourable;  and  with  pneumonia,  or  peripneumonia  notha,  still 
more  so.     Consumptive  subjects  rarely,  if  ever,  recover.     The 
favourable  circumstances  are,  absence  of  fever  and  oppression ; 
free  expectoration,  and  facility  of  vomiting.     The  disease  ter- 
minates sometimes  by  the  gradual  wasting  of  strength,  or  runs 
into  chronic  affections,  as  consumption,  asthma,  hydrothorax, 
and  hydrocephalus ;  or  suddenly  by  apoplexy,  or  suffocation 
from  spasm  of  the  glottis. 

1472.  It  is  obvious,  that  the  irritation  of  the  remote  cause, 
wherever  it  may  be  seated  primarily,  induces  an  inflammation 
of  the  mucous  membrane  of  different  parts  of  the  organs  of  re- 
spiration, occasioning  an  increased  secretion  of  fluid ;  which,  ac- 
cumulating, acts  as  an  extraneous  substance,  and  brings  on  the 
cough  for  its  expulsion.    When  this  natural  effort  succeeds,  there 
is  for  a  time  a  complete  interruption  of  the  coughing;  but  upon 
its  being  reproduced,  we  have  a  repetition  of  the  paroxysm.  By 
too  long  a  continuance  of  this  irritation,  disorganization  takes 
place  in  the  lungs ;  and  the  system  at  large  participating  in  the 
morbid  affection,  a  gradual  exhaustion  of  strength,  and  death 
takes  place:  or  the  air-cells  being  choked  up,  or  the  glottis  closed 
by  spasm,  or  by  collection  of  mucus,  or  lymph,  the  patient  dies 

*  Management  of  Children,  &c.  p.  281. 


430  PERTUSSIS,    OR    HOOPING-COUGH. 

suddenly  from  suffocation :  or  possibly  in  some  instances  as  is 
represented,  the  brain  may  become  so  affected  as  to  constitute  a 
new  and  more  complicated  case,  terminating  life  by  coma,  con- 
vulsions, &c. 

1473.  At  this  period,  an  inflammatory  state  of  the  system  un- 
doubtedly exists.  It  however  exhibits  a  very  peculiar  character, 
owing  perhaps  to  the  nature  of  the  cause  by  which  it  is  excited  ; 
for  it  unquestionably  is  far  less  obedient  to  the  usual  remedies 
than  ordinary  inflammation  ;  and  in  many  respects  proves  illus- 
trative of  the  modification  which  this  condition  receives  from 
the  agent  producing  it. 

1474.  Dr.  Watt  regards  this  disease  as  essentially  an  inflam- 
mation of  the  mucous  membrane  of  the  bronchia;  and  that  when 
it  terminates  fatally,  it  is  generally  by  the  production  of  severe 
bronchitis.     Dr.  Hastings  says,  "  these  cases,"  (cases  that  termi- 
nate speedily  in  death,)  "do  not  differ  from  bronchitis.    Dissec- 
tion shows  the  trachea  and  bronchia  highly  inflamed,  and  the 
latter  and  the  air-cells  filled  with  a  whitish  pus-like  fluid."     p. 
201. 

1475.  Laennec  says,  that  hooping-cough  holds  a  middle  place 
between  the  mucous,  and  pituitous  catarrh,  as  far  as  regards  the 
nature  of  the  expectoration,  and  the  bronchial  congestion;  but 
that  it  possesses  some  characters  peculiar  to  itself. 

1476.  Such,  as  its  rarely  occurring  twice  in  the  same  person; 
the  cough  taking  place  by  fits  ;  "  each  fit,"  he  says,  "is  com- 
posed of  a  quick  succession  of  sonorous  coughs,  with  scarcely 
any  perceptible  inspiration  between ;  except  that  from  time  to 
time  the  expirations  of  coughing  are  suddenly  interrupted  by  a 
very  deep,  seemingly  convulsive,  and  noisy  inspiration,  accom- 
panied by  a  lengthened  hissing,  which  constitutes  the  pathogno- 
monic  sign  of  this  variety  of  catarrh.  The  stethoscope  exploration 
of  the  chest  in  the  intervals  of  the  fits,  supplies  only  the  usual 
results  of  catarrh — namely,  a  feebler  respiration  than  natural,  or 
the  complete  absence  of  this  in  certain  points  which  however 
sound  well — puerile  respiration  in  other  parts,  and  occasionally, 
a  slight  sonorous  or  sibilous  mucous  rattle."  p.  96. 

1477.  Desruelles  makes  it  consist  of  an  inflammation  of  the 
bronchia,   complicated  with  cephalic  irritation.     But  that  the 
"  inflamation  des  bronches  est  toujours  primative,  et  1'irritation 
du  cerveau  consecutive."  p.  77.     We  can  readily  imagine  that 
the  brain,  or  its  appendages  may  indirectly  become  implicated 
with  hooping-cough;  since  the  very  efforts  of  the  thorax  during 
the  paroxysms  are  well  calculated  to  force  an  unusual  quantity 
of  blood  into  the  brain — we  therefore  need   not  be  surprised 
that  dissections  have  revealed  water  in  its  ventricles ;  though 
we  cannot  admit  that  the  inflammation  which  terminated  by 


PERTUSSIS,    OR    HOOPING-COUGH.  431 

the  effusion  of  water,  was  the  cause  of  the   affection  of  the 
lungs.  .  •;•'••'. 

1478.  Desruelles  considers  the  character  of  hooping-cough, 
as  essentially  inflammatory,  under  all  its  modifications,  and  ap- 
pearances.   He  says,  "d  quelques  causes  que  puissent  etre  attri- 
butes les  modifications  qui  presente  la  coquecluche ;  quelles  que 
soient  1'activittj  ou  la  lenteur  de  sa  marche ;  la  violence  ou  la  fai- 
blesse  de  ses  symtomes,  la  promtitude  ou  le  retard  de  sa  gueri- 
son,  son  etat  de  simplicite  ou  de  complication,  son  issue  heureuse 
ou  funeste,  cette  affection  offre  toujours  les  caracteres  d'une  ma- 
ladie  inflammatoire  dont  les  differens  degres,  sont  les  principales 
causes  des  formes  diverses  qu'elle  revet.'-'  p.  27. 

1479.  We  are  every  way  willing  to  admit,  that  hooping- 
cough  is  an  inflammatory  disease;  but  we  are  tenacious  that  this 
inflammation  should  be  located  primarily  and  consecutively,  in 
the  mucous  membrane  of  the  bronchia,  because  post  mortem 
examinations  prove  this  fact,  and  because,  almost  all  the  pheno- 
mena of  this  disease  declare  the  same  thing.     For  in  its  com- 
mencement, the  lungs  are  primarily  affected,  as  is  evidenced  by 
cough,  and  sometimes  by  the  rapid  formation  and  expectoration 
of  mucus.     In  its  progress,  especially  in  the  severer  cases,  by  a 
sense  of  suffocation,  and  difficulty  of  breathing;  and  in  its  ter- 
minations, by  a  proper  expectoration  of  phlegm,  when  it  eventu- 
ates favourably,  or  by  suffocation,  when  its  issue  is  fatal,  while 
the  cerebral  affections  appear  to  be  secondary,  if  they  even  show 
themselves.     Some  look  upon  the  disease  to  be  entirely  spas- 
modic. 

1480.  This  last  opinion  is  principally  derived  from  the  fitful 
nature  of  the  coughing  paroxysms,  the  debility  which  sometimes 
attends  the  disease,  and  the  convulsive  action  of  the  moving 
powers  of  the  chest.     But  this  opinion  must  be  given  up  upon 
the  evidence  revealed  by  dissections,  of  mechanical  obstructions 
existing  in  the  air-cells,  and  bronchia  of  the  lungs.  For  it  is  one 
of  the  functions  of  inflamed  surfaces  to  throw  out  lymph  or  se- 
rum ;  and  this  is  performed  in  hooping-cough  with  so  much  cer- 
tainty, that  we  never  see  the  disease,  without  it  being  attended 
with  a  profuse  secretion  of  mucus ;  and  this  sometimes  to  such 
an  extent,  as  to  destroy  the  patient,  by  preventing  the  due  oxy- 
genation  of  the  blood,  by  interrupting  the  ingress  of  air  from 
without. 

1481.  But  it  may  not  always  be  necessary  to  danger,  that  an 
immoderate  secretion  of  mucus  should  take  place ;  for  a  high 
state  of  inflammation  of  the  membrane  of  the  air-cells  and  bron- 
chia, may  be  every  way  sufficient  to  prevent  a  due  oxygenation 
of  the  blood;  as  these  membranes  cannot  perform  a  healthy  func- 
tion, while  labouring  under  a  powerful,  and  perhaps  an  over- 


432  PEKTUSSIS,   OR    HOOPING-COUGH. 

whelming,  diseased  action — hence  the  sudden  relief  experienced 
sometimes  from  the  loss  of  a  few  ounces  of  blood,  where  severe 
oppression  of  the  chest,  lividity  of  the  lips,  and  cheeks  were 
found.- 

1482.  It  will  therefore  follow  as  a  consequence,  that  the  vio- 
lence and  obstinacy  of  the  disease  will  very  much  depend  upon 
the  extent  and  degree  of  the  inflammation  of  the  larynx,  trachea, 
bronchia,  and  air-cells;  for  several  or  all  may  be  involved  atone 
and  the  same  time.     For  the  inflammation  may  be  so  limited  in 
extent,  and  so  mild  in  degree,  as  to  create  but  little  general,  or 
even  local  injury;  or  it  may  involve  so  much  structure,  as  to  oc- 
casion death,  immediately,  by  suffocation,  or  remotely,  by  pro- 
ducing phthisis  in  those  who  may  labour  under  tubercular  pre- 
disposition.    When  we  speak  however  of  suffocation,  we  do  not 
mean  that  it  is  always  by  mechanical  obstructions  in  the  air-cells; 
but  from  the  want  of  the  necessary  decarbonation  of  the  blood ; 
a  thickening,  or  turgescency  of  the  mucous  membrane,  of  the 
air-cells  and  bronchia,  as  just  noticed  above ;  giving  rise  to  the 
circulation  of  black  blood — and  hence  perhaps  the  sudden  and 
extreme  debility,  that  sometimes  takes  place  in  this  complaint, 
from  the  effect  that  black  blood  exerts  upon  the  nervous  system. 

Treatment. 

1483.  Notwithstanding,  a  more  correct  light  has  been  shed 
on  the  pathology  of  hooping-cough,  little  new  is  proposed  for  its 
management. 

*  1484.  As  the  whole  of  the  phenomena  of  this  disease  at  its 
commencement  declare  it  to  be  catarrhal ;  and  as  in  most  in- 
stances, in  the  colder  parts  of  our  seasons,  it  is  attended  with 
fever,  and  marks  of  local  irritation,  and  inflammation,  there  is 
the  most  decided  necessity  of  treating  this  complaint,  by  evacu- 
ants;  as  blood-letting,  laxatives,  and  vomiting;  and  these  must 
be  repeated,  according  to  the  exigency  of  the  case.  These  re- 
medies should  be  persevered  in,  until  they  produce  direct  evi- 
dence, that  the  inflammatory  stage  of  the  disease  is  abated,  or 
subdued ;  or,  in  other  words,  let  the  disease  in  the  first  instance, 
be  considered  as  a  violent  catarrh,  and  be  treated  accordingly. 

1485.  We  are  persuaded  that  this  disease  oftentimes  becomes 
inveterate,  and  sometimes  dangerous,  from  prescriptions  being 
based  upon  a  mistaken  pathology.  Thus  both  Burton*  and  Mil- 
lart  reject  blood-letting  altogether;  though  Millar  sometimes 
ventured  upon  the  application  of  leeches.  LieutaudJ  never  em- 

*  Appendix  to  treatise  on  the  non  naturalis. 

f  Observations  on  the  Asthma  and  Hooping-Cough. 

*  Med.  Prat. 


PERTUSSIS,   OR    HOOPING-COUGH.  433 

ployed  it,  but  in  extreme  cases;  that  is,  when  the  fever  was  very 
violent,  and  the  respiration  difficult,  &c.  We  would  therefore 
wish  the  reader  to  keep  in  mind  the  opinion  of  Laennec,  Des- 
ruelles,  Watt,  and  others,  that  in  hooping-cough  the  bronchia,  or 
other  portions  of  the  lungs,  are  sure  to  be  in  a  state  of  inflam- 
mation, especially  in  its  commencement ;  and  if  proper  deple- 
tion be  neglected,  a  second  stage  of  the  disease  is  formed,  and  in 
which  we  find  a  disposition  either  to  metastasis  to  the  brain,  or 
that  this  organ  already  participates  severely  with  the  original 
complaint,  hence,  convulsions,  inflammation  of  the  brain,  or  hy- 
drocephalus,  are  found  to  supervene. 

1486.  Bleeding  is  demanded  in  many  instances,  independently 
of  other  circumstances,  by  the  interrupted  circulation  through 
the  lungs ;  and  it  affords  almost  always,  the  most  decided  relief.* 
And  this  must  be  repeated  as  the  necessity  for  it  may  continue ; 
or  as  this  necessity  may  subsequently  return,  in  the  progress  of 
the  case.  Even  in  Europe,  where  the  lancet  is  comparatively  so 
sparingly  resorted  to,  this  practice  is  commended,  and  generally 
adopted ;  but  in  this  country,  its  employment,  for  the  most  part, 
is  indispensable. 

1487.  This  was  the  practice  of  Willis,  who  was  the  first  to 
give  a  regular  account  of  this  disease  ;t  he  chiefly  relied  for  its 
cure  upon  vomiting,  purging,  and  blistering.    This  appears  too, 
to  have  been  the  general  practice  of  the  age,  and  particularly  of 
Sydenham  and  Hoffman ;  and  among  many  inferior  names,  we 
have  those  of  Astruc,  Huxham,  Hillary,  Home,  Lettsome,  &c. 
in  favour  of  this  course  of  treatment. 

1488.  Evacuations  from  the  alimentary  canal  must  be  brought 
in  aid  of  bleeding;  and  these  may  be  made  by  emetics,  or  laxa- 
tives, according  to  circumstances;  the  best  laxative  is  castor  oil, 
after  the  bowels  have  once  been  well  opened  by  calomel.  Eme- 
tics are  chiefly  applicable  to  children ;  and  where  the  attack  is 
violent,  and  the  oppression  great,  they  are  to  be  repeated,  pro- 
vided the  accumulation  of  phlegm  is  great  and  threatening.    To 
keep  up  the  impression  on  the  stomach,  small  doses  of  the  syrup 
of  squills,  or  ipecacuanha,:]:  should  be  given  in  the  intervals.  Or 
what  has  answered  all  these  intentions  with  the  most  decided 
efficacy,  is  Coxe's  hive  syrup,  given  in  proper  doses. § 

*  By  bleeding  we  wish  to  be  understood  constantly,  the  taking  of  blood  from 
the  general  system,  by  means  of  the  lancet. 

f  This  was  in  1664. 

+  We  would  use  the  vinegar  of  squills,  where  there  was  but  little  fever;  and 
the  ipecacuanha,  where  this  was  considerable — or  we  may  join  the  tartrite  of 
antimony  with  the  vinegar  of  squills  with  much  advantage. 

§  The  hive  syrup,  it  is  true,  contains  both  squills  and  seneka,  but  the  stimu- 
lating effect  of  both  these  articles,  is  controlled  by  the  emetic  tartar,  and  on 
which  it  almost  exclusive*!}'  depends  for  its  emetic  properties.  In  cases  not 

55 


434  PERTUSSIS,    OR    HOOPING-COUGH. 

1489.  We  always  have  recourse  to  this  medicine  immediately 
after  the  reduction  of  the  pulse  by  bleeding,  if  this  have  been  ne- 
cessary, and  after  having  purged  with  calomel.     The  hive  syrup 
must  be  given  in  such  doses  as  shall  promote  expectoration ;  or 
should  there  be  oppression,  or  evidence  of  great  accumulation  of 
phlegm  in  the  windpipe  and  lungs,  in  such  quantity  as  shall 
freely  puke.     We.  for  the  first  purpose,  order  doses  suitable  to 
the  age  of  the  child,  every  hour  or  two,  as  it  may  show  its 
effects.     For  a  child  of  three  or  four  months  old,  we  would  or- 
der eight  drops  every  hour  or  two,  and  a  proportional  larger 
quantity,  as  the  age  of  the  child  is  advanced ;  and,  for  the  second 
view,  we  would  give  this  quantity  or  more  every  fifteen  minutes, 
until  an  emetic  operation  be  produced.     Let  it  be,  however,  re- 
membered, that  children  of  the  same  age  will  bear  very  different 
quantities  of  this  medicine,  as  well  as  of  every  other ;  therefore 
the  dose  must  be  constantly  regulated  by  the  effects.    After  this 
medicine  has  operated  as  an  emetic,  it  must  be  given  as  before 
directed,  as  an  expectorant.*    But  should  bleeding  not  have  been 
necessary,  the  case  will  rarely  require  more  than  demulcent 
drinks,  and  a  low  diet. 

1490.  The  state  of  the  expectoration  is  a  matter  of  consequence, 
and  should  always  be  attended  to;  for  from  it  much  may  be  learn- 
ed.  In  favourable  cases,  after  the  disease  has  arrived  at  its  height, 
or  is  upon  the  decline,  the  expectoration  becomes  more  profuse, 
and  the  sputa  lose  their  mucous  character  by  assuming  a  more 
purulent  appearance.     But  if  this  take  place  suddenly,  or  in  the 
early  part  of  the  disease,  it  is  for  the  most  part  an  unfavourable 
sign.     Nor  is  blood  mixed  with  the  expectorated  matter,  a  good 
token,  generally  speaking. 

1491.  The  most  abstemious  diet  should  be  observed  during 
the  whole  of  the  catarrhal  stage  of  this  complaint,  which  is  from 
three  to  six  weeks,  according  to  the  season.     Children  at  the 
breast  should  receive  nothing  but  the  mother's  milk;  and  those 

accompanied  with  much  arterial  excitement,  we  do  not  hesitate  to  commence 
with  it,  if  the  promotion  of  expectoration  be  desirable,  or  if  the  removal  of 
phlegm  by  puking,  be  necessary. 

*  The  following  is  the  recipe  for  making  the  compound  syrup  of  squills,  or 
Coxe's  hive  syrup. 

Take  of  Seneka  snake-root  bruised,  ?       .   half  a  nound. 
Squills  dried  and  bruised,    5 
Water,    -        ...       eight  pounds. 

Boil  together  over  a  slow  fire  till  the  water  is  half  consumed;  strain  off  the 
liquor,  and  then  add  of  strained  honey  four  pints. 

Boil  the  honey  and  the  strained  liquor  to  six  pounds,  or  to  the  consistence 
of  a  syrup;  and  to  every  pound  of  the  syrup,  add  sixteen  grains  of  tartar  eme- 
tic; that  is,  one  grain  to  every  ounce.  It  is  best  to  have  the  tartar  emetic  dis- 
solved previously  in  some  hot  water,  that  it  be  equally  distributed  through  the 
syrup. 


PERTUSSIS,    OK    HOOPING-COUGH.  435 

who  are  weaned  should  be  confined  strictly  to  a  milk  and  vege- 
table diet.  All  animal  food,  or  broths,  must  most  scrupulously 
be  avoided.  Rennet  whey  is  preferable  t<5  whole  milk.  The 
drinks  should  be  barley  water,  flaxseed  tea,  slippery-elm  bark 
tea,  gum  Arabic  water,  bran  tea,  toast  water,  molasses  and  water, 
&c.  The  milder  laxatives,  though  recommended  by  many,  do 
not  answer  as  well  as  calomel  for  the  first  purging;  for,  inde- 
pendently of  its  purgative  effects,  this  medicine  would  seem  to 
exercise  some  other  power.  Certain  it  is,  that  active  evacuations 
by  calomel  in  the  commencement  of  the  disease,  have,  in  a 
greater  or  less  degree,  the  effect  of  breaking  down  the  force  of 
the  calarrhal  symptoms,  and  to  abridge  the  career  of  the  disease. 
We,  therefore,  almost  always  commence  the  treatment  with  a 
mercurial  purge ;  and  repeat  this  for  the  first  two  or  three  days 
if  the  condition  of  the  bowels  require  it.  But,  whatever  opinion 
We  may  adopt  of  its  mode  of  action,  we  are  certain  of  its  utility; 
and,  as  there  can  be  no  dispute  as  to  the  propriety  of  having  the 
bowels  well  opened  in  the  beginning  of  the  disease,  calomel 
seems  to  be  suited  to  the  best  purposes. 

1492.  During  the  general  treatment  which  we  have  pointed 
out,  we  are  not  wholly  to  lose  sight  of  some  local  remedies  in 
this  disease.     Congestion  and  inflammation  of  the  lungs  are  apt 
to  take  place;  for  the  relief  of  which,  blisters  are  found  decidedly 
advantageous  after  proper  evacuations ;  or  should  it  be  necessary 
to  draw  more  blood,  let  it  be  done  by  leeches,  or  cups,  from  be- 
tween the  shoulders.     We  are  decidedly  of  opinion,  that  blood 
cannot  be  taken  by  leeches  or  cups  with  any  thing  like  the  same 
advantage  from  any  other  part,  when  congestion  of  the  lungs  is 
threatened ;  and  it  sometimes  becomes  important  to  follow  this 
up,  by  a  blister,  to  the  same  part. 

1493.  When  there  is  a  strong  determination  to  the  head,  the 
same  remedies  are  required ;  both  general,  and  local.     Leeches 
to  the  temples  we  have  found  of  singular  advantage,  where  much 
pain  in  the  head  has  been  experienced  after  each  spell  of  cough- 
ing; indeed  we  now  never  neglect  this  last  symptom;  as  we  are 
convinced  it  was  the  prelude  to  fatal  issue  in  two  or  three  cases 
we  have  seen,  by  extravasations  within  the  brain — an'd  who  has 
not  witnessed  the  advantage,  or  at  least  the  immediate  relief, 
from  an  accidental  bleeding  from  the  nose? 

1494.  Though  we  admit  of  determination  of  blood  to  the  head 
in  this  disease,  and  recommend,  as  just  stated,  local  depletion 
for  its  relief,  we  are  by  no  means  of  opinion  th.at  Either  this  de- 
termination, or  an  inflammation  of  the  brain  or  its  appendages, 
have  the  least  agency  in  the  production,  or  even  the  perpetua- 
tion of  the  cough,  with  which  either  may  be  associated.  Yet  the 
supervention  of  inflammation,  or  even  a  congestive  state  of  the 


436  PERTUSSIS,    OR    HOOPINO-COTTGH. 

brain,  will  very  much  increase  the  danger  of  the  patient — there- 
fore these  conditions  require  the  active  means  just  recommended 
for  their  relief.  Nature  sometimes  furnishes  the  means  of  relief 
herself,  by  instituting  a  bleeding  from  the  nose — this,  when  suf- 
ficiently extensive,  affords  more  relief  than  either  cupping  or 
leeching,  and  should  therefore  always  be  encouraged  to  as  great 
an  extent  as  may  be  compatible  with  the  exigency  of  the  symp- 
toms, and  the  strength  of  the  patient,  if  this  be  practicable;  but 
this  is  rarely  so,  as  the  discharge  from  the  nose  is  almost  always 
small  in  these  cases. 

1495.  But  let  it  be  remembered,  that  the  bleeding  from  the 
nose,  however  instrumental  or  speedy  it  may  be  in  abating  the 
violence  of  the  marks  of  determination  to  the  head,  or  of  conges- 
tion in  the  brain,  only  proves  the  immediate  condition  of  these 
parts,  and  not  an  original  agency,  in  the  production  of  hooping- 
cough. 

1496.  In  the  use  of  the  remedies  recommended  above,  we 
would  wish  it  to  be  understood,  that  we  do  not  always  prescribe 
bleeding,  or  the  loss  of  blood  in  any  other  way,  in  every  case  of 
hooping-cough,  as  it  very  often  presents  itself  without  the  symp- 
toms which  would  justify  this,  or  perhaps  any  other  depleting 
remedy,  except  occasionally  the  use  of  the  syrup  as  just  di- 
rected, to  secure  a  free  expectoration,  or  the  administration  of  a 
few  grains  of  calomel,  or  what  is  better,  after  the  few  first  days 
of  the  disease,  is  the  occasional  use  of  castor  oil,  if  the  bowels  be 
confined. 

1497.  If  due  regard  hav«  hep.n  paid  to  the  treatment  of  the 
inflammatory  or  catarrhal  stage  of  hooping-cough,  or  if  the  re- 
medies for  subduing  this  state  have  been  successful,  a  second 
period  of  this  disease  will  arrive,  in  which  other  remedies  may 
be  useful. 

1498.  But  it  should  be   carefully   ascertained,    before   the 
character  of  the  remedies  are  changed,  that  every  vestige  of 
inflammatory   action   shall   have  ceased ;   therefore   the   pulse 
must  be  carefully  examined,  and  it  must  be  found  sufficiently 
subdued,  before  we  commence  with  the  antispasmodic  and  tonic 
remedies. 

1499.  Desruelles  finds  much  fault  with  these  directions;  and 
says,   "comment  se  fait-il  que  le  Doctor  Dewees,  qui  montre 
tant  de  confiance  dans  le  regime,  qui  le  present  avec  tant  de  r6- 
serve  et  de  sagesse,  ait  cru  necessaire  de  donner  Pemetique,  d'en- 
tretenir  les  nausees  par  des  petits  doses  d'ipecacuanha,  de  purger 
souvent  avec  calomelas,  et  de  s'abandonner  £  1'action  incertaine 
et  souvent  nuissible  des  narcotiques  des  antispasmodiques  et 
mSme  des  toniques  ?  il  preconise  la  saignie  et  la  diete,  et  il  ad- 
ministre  des  mldicamens  stimulans ;  n'est-ce  pas  detruire  d'une 


PERTUSSIS,   OR    HOOPING-COUGH;  437 

main  ce  que  1'on  a  fait  de  1'autre.  Par  quelle  6trange  assoc'atiort 
d'idees  peut  on  faire  concourir  au  meme  resultat  des  troyens  se 
opposes,  et  si  contradictoires?"  p.  242. 

1500.  In  answer  to  the  above  questions,  it  will  be  only  neces- 
sary to  say,  we  differ  a  little  in  the  progressive  pathology  of 
hooping-cough,  and  on  this  circumstance,  does  the  difference  of 
our  treatment  arise.  Desruelles  considers  the  bronchia  at  least,  if 
not  the  brain  or  its  appendages  to  be  in  a  state  of  phlogosis  during 
the  whole  continuance  of  the  cough ;  while  we  are  of  opinion, 
that  the  stage  of  inflammation  passes  away ;  and  that  if  the  cough 
continue,  after  the  pulse  declares  the  absence  of  febrile  action, 
that  it  arises  from  some  impression  made  upon  the  nervous  sys- 
tem ;  or  that  it  may  then  become  the  cough  of  habit.  With  this 
belief  in  view,  we  prescribe  a  rigid  diet,  order  bleeding,  either 
general,  or  topical,  or  both,  purging,  &c.  but  after  the  necessity 
for  this  discipline  has  ceased,  we  think,  we  have  always  found  it 
useful  to  give  either  antispasmodics,  or  tonics. 

1501.  We  do  not  order,  as  will  be  perceived,  two  different 
plans  at  one  and  the  same  time ;  for  we  have  just  insisted,  that 
"  before  the  character  of  the  remedies  are  changed,  we  should 
carefully  ascertain  that  every  vestige  of  inflammatory  action  has 
ceased."    There  is  certainly  no  inconsistency  in  this  practice — 
nay  it  is  very  often  essential  to  the  cure  of  many  affections,  as 
fevers,  and  especially  intermittents,  that  the  system  be  reduced 
before  tonics  are  given. 

1502.  We  have  just  stated  that  Desruelles  looks  upon  the 
hooping-cough  to  be  essentially  an  inflammatory  disease  under 
all  its  modifications,  and  through  the  whole  of  its  career;  and  that 
it  consequently  requires  an  antiphlogistic  treatment  from  its  com- 
mencement to  its  final  departure.     But  as  we  have  never  had 
any  reason  to  be  of  this  opinion  ourselves,  we  have  not  adopted 
the  notions  of  this  author  upon  this  point.  The  difference  of  our 
views  of  the  character  of  this  disease  during  its  progress,  will 
readily  account  for  the  difference  of  our  plans  of  treatment ;  we 
might  therefore  retort  his  queries  with  equal  propriety,  when 
he  insists  upon  one  uniform  mode  of  practice  through  the  whole 
course  of  the  disease ;  for  to  us  it  appears  as  inconsistent,  as  our 
plan  does  to  him. 

1503.  In  justice  however  to  him,  we  have  to  acknowledge, 
that  we  have  seen  a  number  of  cases  of  hooping-cough  subdued, 
and  that  speedily  in  some  instances,  by  a  perseverance  in  the 
antiphlogistic  plan  of  treatment;  but  injustice  also  to  ourselves 
we  must  say,  that  we  have  seen  very  many  more,  that  required 
the  change  in  treatment,  that  we  have  laid  down. 

1504.  We  believe  it  has  been  chiefly  owing  to  want  of  atten- 
tion to  the  state  of  the  pulse,  that  this  disease  has  not  yielded 


438  PERTUSSIS,    OR    HOOPING-COUGH. 

more  generally  to  the  influence  of  remedies — for  it  has  been  pre- 
scribed for  more  empirically,  than  almost  any  other  complaint  in 
the  long  catalogue  of  human  diseases.  When  the  first  stage  has 
been  neglected,  or  improperly  treated,  the  disease  will  pursue 
its  course  in  spite  of  all  opposition ;  and  the  patient  may  be  feli- 
citated when  it  takes  its  departure,  however  protracted  this  may 
be,  and  leaves  not  behind,  more  serious  evils  than  were  experi- 
enced by  its  presence. 

1505.  We  have  no  confidence  in  the  opinion,  that  this  disease 
will  have  a  determined  course;  and  that  we  can  only  relieve  the 
pressure  or  inconvenience  of  the  immediate  symptoms,  though 
urged  by  Sydenham  himself.    Nor  shall  we  inculcate  this  belief, 
unless  it 'were  a  well  ascertained  fact,  as  it  would  but  too  cer- 
tainly foster  supineness  and  indifference  in  the  treatment  of  this 
formidable  disease. 

1 506.  Too  much  has  already  been  taken  for  granted  upon  this 
subject;  and  though  we  are  not  in  possession  of  proper  counter- 
agents  for  this  complaint,  it  certainly  does  not  prove  it  to  be  in- 
domitable. The  intermittent  fever,  and  lues  venerea,  were  once 
thought  to  be  equally,  if  not  more  unmanageable,  than  hooping- 
cough  ;  but  the  discovery  of  the  bark,  and  the  use  of  mercury, 
have  rendered  them  comparatively  harmless  diseases ;  the  pro- 
per or  appropriate  remedy  for  hooping-cough  may  therefore  be 
yet  discovered. 

1507.  If  the  opinion  prevail,  that  hooping-cough  will  have  a 
definite  duration,  all  exertions  to  abridge  its  career  will  be  pa- 
ralized,  and  the  poor  suffering  infants  and  children  will  be  de- 
prived of  even  the  moderate  aid  it  is  now  in  our  power  to  give. 
As  regards  ourselves,  we  are  decidedly  of  opinion,  that  its  dura- 
tion may  as  certainly  be  shortened,  as  the  march  of  fever;  nor  do 
we  say  this  upon  slight  or  inadequate  grounds  if  our  observations 
have  not  deceived  us.     We  have  known  this  disease  to  be  made 
run  its  course  in  eight  members  of  the  same  family,  and  at  the 
same  time  in  less  than  six  weeks;  and  in  many  other  instances 
the  period  has  been  abridged  with  equal  success.     But  what  has 
entirely  confirmed  us  in  the  persuasion,  that  the  period  of  this 
disease  can  be  shortened,  nay,  even  stopped  short  in  some  in- 
stances, was  the  success  we  once  witnessed  from  the  exhibition 
of  the  tincture  of  artificial  musk,  in  a  family  of  five  children, 
who  were  all  labouring  under  confirmed  hooping-cough. 

1508.  When  we  prescribed  this  remedy,  the  disease  had  been 
of  about  two  weeks  standing;  all  the  children  were  attacked 
within  the  period  of  a  week;  the  catarrhal  symptoms  were  very 
mild;  it  was  summer,  and  they  readily  yielded  to  a  moderate 
antiphlogistic  plan.      All  inflammatory  action  was  completely 
subdued,  and  all  the  children  were  put  upon  the  use  of  the  arti- 


PERTUSSIS,    OR    HOOPING-COUGH.  439 

ficial  musk  at  the  same  time.  One,.the  youngest,  (eleven  months 
old,)  ceased  to  cough  altogether  in  less  than  a  week,  and  neither 
of  the  others  continued  as  much  as  a  fortnight. 

1509.  We  however  confess,  we  have  not  seen  so  striking  an 
instance  of  the  influence  of  this  article  since;  though  we  are 
every  way  convinced,  it  is  a  valuable  remedy  in  this  disease^ 
and  one  that  we  have  long  been  in  the  habit  of  using. 

1510.  Another  disadvantage  arising  from  the  belief  that  this 
disease  cannot  be  shortened,  is,  the  neglect  of  early  measures  to 
subdue,  or  moderate  the  inflammatory  action  of  the  system  in 
its  commencement.   In  consequence  of  this,  cerebral  and  pulmo- 
nic  congestions  form,  of  which  the  patient  perhaps  speedily  dies, 
or  such  disorganization  takes  place  as  to  render  him  miserable 
for  life.    This  doctrine  is  not  understood  by  peaple  in  general — 
for  when  it  is  declared  we  cannot  abridge  the  period  of  the  dis- 
ease, it  is  always  understood  to  mean,  that  we  can  do  no  good  in, 
hooping-cough ;  of  course  the  physician  is  but  too  rarely  em- 
ployed in  this  complaint. 

1511.  Yet  we  are  certain,  there  are  few  diseases,  in  which 
more  relief  is  experienced  than  hooping-cough,  when  treated  in 
the  commencement  of  the  disease;  of  this  opinion  also  was  the 
experienced  Dr.  Underwood,  who  declares,   "there  is  no  com- 
plaint of  children,  with  which  I  am  acquainted,  in  which  medi- 
cine is  at  times  more  evidently  serviceable,  than  in  bad  hooping- 
cough.'-     Then  why  should  patients  be  abandoned  in  this  for- 
midable complaint,  for  an  ill-sustained  hypothesis? 

'  1512.  Narcotics,  and  antispasmodics,  are  also  directed  at  this 
period  of  the  disease,  and  of  these,  opium  claims  our  first  notice. 
After  evacuations  have  been  duly  made,  and  there  is  a  proper 
abatement  of  fever,  or  other  marks  of  irritation,  its  use  as  a  pal- 
liative of  the  more  troublesome  symptoms,  is  sanctioned  by  the 
experience  of  almost  every  body.  The  pleasantest,  and  we  be- 
lieve the  best  form  for  its  exhibition,  is  the  brown  mixture  in 
suitable  doses  at  night.* 

1513.  During  the  prevalence  of  the  pathology  that  ascribed 

*  The  following  is  the  formula  for  the  brown  mixture;  so  called  from  its  co- 
lour:— 


R.  Elix.  paregor.  !fj. 

Vin.  antimon.  -  -  ^ss. 
Sue.  Glycyrrh.  -  -  giij. 
Pulv.  G.Arab.  -  -  gij. 
Aq.  fervent  -  -  gvj. 

M.  ft.  sol. 


Take  Paregoric  elixir          1  ounce. 
Antimonial  wine         £  ounce. 
Liquorice  ball       -     3  drachms. 
Gum  Arabic          -     2  drachms. 
Hot  water    -        -      6  ounces. 
Mix. 


Of  this  a  child  from  four  months  to  six  may  take  a  small  tea-spoonful  every 
two  or  three  hours  during  the  night,  should  the  cough  be  troublesome;  one 
from  six  months  to  a  year,  a  large  tea-spoonful,  and  repeat,  if  necessary;  one 
from  one  to  two  years,  a  dessert-spoonful,  and  repeat;  one  from  two  to  four,  a 
table-spoonful,  and  so  on  as  age  increases. 


440  PERTUSSIS,    OR    HOOPING-COUGH. 

the  disease  to  spasm,  antispasmodics  were  the  chief  remedies. 
Of  this  class  of  remedies,  almost  the  whole  were  tried  in  suc- 
cession, and  particularly  the  castor,  artificial  musk,  and  asafoe- 
tida.  Of  the  powers  of  the  former  we  are  entirely  ignorant, 
having  never  prescribed  it.  Cullen,  however,  tells  us,  that  it  is 
of  no  value. 

1514.  The  second,  or  artificial  musk,  has  been  long  in  use  in 
spasmodic  affections,  and  its  powers  have  been  in  some  degree 
ascertained.     It  is  only,  however,  within  a  few  years,  that  an 
application  has  been  made  of  it,  for  the  cure  of  pertussis ;  and  we 
have  already  said,  that  we  have  found  it  sometimes  a  valuable 
remedy.     It  is  also  highly  estimated  by  Underwood;  and  espe- 
cially where  the  spasms  are  violent;  it  is  given  in  the  dose  of 
five  or  six  drops  on  sugar,  or  highly  sweetened  milk. 

1515.  Of  the  antispasmodics,  asafretida  has  always  born  a 
high  character;  but  our  own  experience  is  by  no  means  calcu- 
lated to  advance  the  reputation  of  its  powers  in  the  disease  in 
question;  we  have  found  it  occasionally  useful,  but  never  of  de- 
cided efficacy. 

1516.  On  the  subject  of  asafoetida,  it  may  be  well  to  say  a 
few  words  more,  as  popular  opinion  is  much  in  its  favour.    Our 
own  experience  we  have  just  stated ;  I  shall  therefore  quote  from, 
those  who  have  had  ample  experience  in  the  employment  of  this 
drug. 

1517.  Dr.  Millar  says,  "when  it,  (asafoetida,)  was  prescribed 
early,  other  medicines  were  seldom  necessary,  the  patient,  while 
using  it,  was  cool,  free  from  thirst,  or  any  other  febrile  symp- 
tom, and  easy  between  the  fits  of  coughing,  which  were  mode- 
rate, and  attended  with  a  discharge  of  phlegm,  by  which  an  ac- 
cumulation of  viscid  humours  in  the  stomach  and  lungs  was 
prevented,  the  appetite  preserved,  and  all  the  excretions  duly 
maintained." 

1518.  On  this,  and  similar  accounts  of  the  success  of  this 
drug,  Dr.  Watt  makes  the  following  remarks.     "Such  is  the 
account  which  Dr.  Millar  gives  of  the  effects  of  asafoetida  in 
chincough;  but  though  no  doubt  partial,  to  his  favourite  remedy, 
he  does  not  appear  by  any  means  to  have  been  blind  to  its  de- 
fects.    Even  in  the  mildest  cases  he  did  not  trust  to  it  alone ; 
and  in  the  more  severe  he  deemed  it  altogether  inadmissible. 
Hence  he  goes  to  remark — 

1519.  "  *  But  though  asafcetida  has  been  given  with  remarka- 
ble success  in  the  early  stage  of  hooping-cough,  yet  I  never  ven- 
ture to  prescribe  it  in  the. advanced  state,  or  when  the  disease 
was  accompanied  by  a  hectic  fever,  haemorrhage,  or  phthisical 
symptoms.    It  is  therefore  not  to  be  imagined,  that  no  other  re- 
medy is  at  any  time  necessary ;  for  as  the  management  must 


PERTUSSIS,    OR    HOOPING-COUGH.  441 

always  depend  upon  particular  circumstances,  no  invariable  rule 
can  be  laid  down ;  thus  on  some  occasions,  emetics,  blisters, 
issues,  and  setons;  and  in  others,  astringent  medicines  may  be 
indicated.' 

1520.  "On  the  whole,"  says  Dr.  Watt,  "even  by  Dr.  Mil- 
lar's own  account,  asafoetida  is  only  to  be  regarded  as  a  remedy 
in  chincough,  when  the  disease  is  mild,  and  when  perhaps  little 
or  no  treatment  is  necessary."*  We  are  persuaded  our  own  ob- 
servations on  the  use  of  this  drug,  have  furnished  us  with  a  num- 
ber of  instances  in  which  it  proved  highly  injurious. 

1521.  We  are  next  to  consider  the  proper  plan,  after  the  cause 
of  the  disease,  whatever  it  may  be,  has  worn  itself  out,  or  is  dis- 
missed from  the  system,  and  when  the  cough  is  kept  up  by  the 
force  of  habit  only;  to  interrupt  the  trains  of  morbid  association, 
tonics  have  been  directed;  and  especially  such,  as  are  supposed 
to  have  the  effect  of  subduing  paroxysmal  tendencies.    The  Pe- 
ruvian bark  was  of  course  placed  at  the  head  of  this  class ;  and  is 
much  celebrated.     Cullen  bestows  on  it  unqualified  praise;  and 
considers  it  by  far  the  most  certain  means;  and  even  says,  when 
given  in  sufficient  quantity,  he  has  seldom  seen  it  fail  of  speedily 
putting  an  end  to  the  disease.     It  is  reasonable  to  suppose,  that 
the  bark  might  be  useful ;  though  it  must  be  confessed  that  we 
have  not  witnessed  such  striking  results  from  it ;  and,  on  ac- 
count of  the  difficulty  of  getting  children  to  take  it  regularly,  it 
is  rarely  prescribed  in  this  city. 

1522.  This  objection,  however,  does  not  apply  to  the  sulphate 
of  quinine;  and  it  deserves  a  fairer  trial  than  we  suspect  it  has 
received.     We  have  employed  it  in  but  one  case ;  but  this  was 
one  of  the  most  forlorn  kind — it  produced  almost  resuscitation. 

1523.  Mr.  Sutcliffe  combined  the  bark  with  cantharides,  and 
administered  it  with  great  success,  he  says,  in  hooping-cough. 
The  following  is  his  formula: — 


Tinct.  cort.  Peruv. 
Elix.  paregor.         - 
Tinct.  canthar.       - 
M. 


Take  Tincture  of  bark     -    3  ounces,. 
k  Paregoric  elixir         -    J  ounce. 
Tincture  of  cantharides  1  drachm. 
Mix. 


Of  this  mixture  small  doses  were  given  three  or  four  times  a  day, 
gradually  increasing  until  a  slight  strangury  was  excited,  and  then 
the  dose  was  diminished,  or  taken  at  longer  intervals.  The  stran- 
gury would  generally  take  place  about  the  third  day ;  and  the 
hooping-cough  seldom  continued  above  six  days  from  the  first 
exhibition  of  the  medicine.  It  however  succeeded  sometimes 
without  exciting  any  strangury,  though  it  generally  produced  its 

*  Watt  on  Chincough,  p.  285,  Sec. 
56 


442  FEKTUSSIS,    OR    HOOPING-COUGH. 

salutary  effects  sooner,  when  that  circumstance  came  on,  whe» 
ther  the  bark  was  joined  with  the  cantharides  or  not. 

1524.  Dr.  Lettsom  informs  us,  that  "during  twenty  years, 
this  ingenious  practitioner,  has  almost  constantly  continued  to 
use  this  medicine  with  the  most  flattering  success.75 

1525.  Dr.  Lettsom  being  desirous  to  know  whether  Mr.  Sut- 
cliffe's  more  mature  experience  led  him  to  place  the  same  confi- 
dence in  this  remedy,  wrote  certain  queries  to  him  respecting 
chincough. 

1526.  Mr.  S.  replied  to  these  several  queries,  and  concluded 
by  remarking,  "I  never  yet  saw  an  unsuccessful  event  after 
using  the  composition  of  bark,  cantharides,  &c.   having  never 
lost  a  patient  in  the  hooping-cough."     Dr.  L.  declares  a  similar 
success  awaited  his  own  trials  of  this  medicine.    Watt,  p.  282.* 

1527.  But  we  never  employed  any  remedy  of  equal  efficacy 
with  the  garlic  in  substance,  to  relieve  the  cough  of  habit  after 
hooping-cough.   We  have  very  often  used  it;  and  we  have  rarely 
seen  it  fail.  The  objections  arising  from  its  smell,  are,  however, 
very  great  in  the  minds  of  some ;  so  much  so,  that  they  cannot 
be  prevailed  upon  to  use  it.     But  children  of  six  or  seven  years 
of  age,  or  even  older,  can  very  often  be  prevailed  upon  to  eat  it, 
and  become  after  a  while  very  much  attached  to  it.     A  child  of 
six  or  seven,  may  begin  by  taking  a  third  of  a  common-sized 
clove,  morning,  noon,  and   evening;   gradually  increasing  the 
dose  as  the  system  becomes  accustomed  to  its  action.     One  of 
ten  years  old,  may  take  half  a  clove  three  times  a  day  ;  increasing 
it  as  it  may  be  necessary;  and  so  on  for  greater  ages. 

1528.  Desruelles  condemns  us  for  the  employment  of  the  gar- 
lic, either  externally,  or  internally;  indeed  he  goes  so  far  as  to 
say,  we  give  a  blind  confidence  in  this  substance.     This  affects 
us  not;  and  so  long  as  we  continue  to  experience  benefit  from  it, 
we  shall  persevere  in  recommending  it  under  the  restrictions 
suggested  above;  namely,  in  the  absence  of  all  febrile  excite- 
ment, and  when  the  cough  appears  to  be  perpetuated  by  habit. 
The  following  case  is  highly  deserving  of  attention.     Miss  M 
W.  aged  twelve  years,  had  the  hooping-cough  in  great  severity, 
notwithstanding  she  was  subjected  to  a  very  active  treatment  in 

•  "  Specific  for  the  Hooping-Cougb.  In  Rust's  Mag.  f.  die  Gesammt.  Heilk. 
(No.  2,  1828,)  it  is  stated  that  Dr.  Meyer,  of  Menden,  has  in  a  few  days  been 
enabled  to  remove  all  the  symptoms  of  pertussis,  by  the  external  application 
of  morphia.  He  directs  a  small  blister  to  be  applied  over  the  prsecordia;  the 
detached  cuticle  being  removed,  the  exposed  surface  is  to  be  sprinkled  over 
with  half  a  grain  of  morphia  rubbed  up  with  starch.  The  morphia  to  be  re- 
peated every  evening.  The  only  internal  remedy  he  employed  was  an  eme- 
tic. If  necessary,  the  blister  may  be  reapplied  every  third  day.  In  five  cases, 
the  disease  was  so  diminished  in  eight  days,  that  no  further  treatment  was  con- 
sidered necessary." — North  American  Med.  and  Surg.  Journ.  No.  XV.  July, 
1829.  p.  197. 


PEKTUSS1S,    OR    HOOflNU-COUUM. 

the  early,  or  inflammatory  stag*  of  the  disease.  It  began  in  March, 
and  the  cough  continued  with  great  violence  until  July,  at  which 
time  we  were  requested  to  prescribe  for  her— at  our  first  visit, 
we  had  an  opportunity  of  witnessing  two  fits  of  coughing;  bo.th 
of  which  spells  exceeded  in  severity  any  thing  we  had  ever  seen; 
she  was  literally  black  in  the  face,  and  was  threatened  with  im- 
mediate suffocation. 

1529.  These  paroxysms  were  repeated  frequently;  especially 
during  the  day;  they  left  her  weak,  and  exhausted;  she  lost  flesh 
daily,  and  was  so  debilitated  as  scarcely  to  be  able  to  walk.   She 
was  ordered  to  eat  a  small  clove  of  garlic  three  times  a  day; 
in  forty-eight  hours  these  paroxysms  left  her  entirely;  a  slight 
cough  remained  for  a  few  days,  and  this  soon  ceased  altogether. 
We  cannot  but  believe  it  was  the  garlic  which  afforded  such 
speedy  and  happy  relief;  particularly,  as  it  has  frequently  proved 
as  certainly,  if  not  as  extensively,  serviceable,  in  other  cases  of 
hooping-cough. 

1530.  Exactly  on  the  same  principle,  the  arsenical  solution  is 
employed;  and  we  have  the  strong  testimonies  of  Simmons  and 
Ferriar  in  support  of  it.     Each  of  these  writers  goes  so  far  as  to 
declare  that  it  is  the  only  medicine  deserving  of  much  confi- 
dence.    Dr.  Bland  recommends  the  sulphuret  of  potash.     He 
gives  it  in  doses  of  ten  grains,  morning  and  evening,  mixed  in  a 
little  honey. — Revue  Med.  Jlug.  1831. 

1531.  On  this  point  we  can  say  nothing  from  our  own  expe- 
rience; as  we  do  not  deem  the  few  trials  we  have  given  this  me- 
dicine, entitled  to  much  weight;  our  impressions  of  its  efficacy 
are  not  strong. 

1532.  We  have  said  nothing  of  the  utility  of  topical  reme- 
dies, in  the  acute  stage  of  the  disease;  for  they  can  rarely  be 
useful:  but  in  the  one  now  under  consideration,  external  applica- 
tions may  be  advantageously  resorted  to ;  such  as  liniments  of 
an  irritating  natdre,  as  the  volatile  or  camphorated;  the  spirit  of 
turpentine  mixed  with  olive  oil;  or  the  juice  of  garlic  rubbed 
along  the  vertebral  column.     But  we  think  we  have  observed 
more  advantage  to  result  from  the  use  of  the  tartar  emetic  oint- 
ment,* than  from  any  other  application — this  should  be  applied 
high  up  between  the  shoulders. 

*  The  following  formula  we  are  in  the  habit  of  using  for  children : — 


R.  Tartrite  of  antimon.  gjss 

Ol.  lavend.  vel  ess.  lem.  gtt.  xx. 

Cerate  simp.      -        -  5j. 
M. 


Take  Tartar  emetic  1£  drachm. 

Oil  of  lavender,  or  es- 
sence of  bergamot,  20  drops. 
Simple  cerate  1  ounce. 


Mix. 

With  this  the  part  indicated  above  must  be  rubbed,  three  times  a  day,  until  it 
shows  a  number  of  small  pimples  upon  it — dress  with  common  cerate.  If  the 
irritation  subside  too  soon,  it  must  be  reexcited  by  the  ointment! 


444  PEKTCSSISj    OK    HOOPING-COUGH. 

15J3.  It  is  well  understood,  how  much  the  action  of  the  lungs 
is  dependent  on  a  nervous  influence  from  the  spinal  marrow; 
and  it  is  probably  on  this  principle,  the  efficacy  of  such  embro- 
cations is  to  be  explained.  The  muscles  of  the  chest,  diaphragm, 
and  scapulas,  receive  portions  of  the  cervical  and  dorsal  nerves ; 
the  accessory  nerves  of  Willis  form  a  part  of  the  par  vagum,  and 
assist  in  giving  rise  to  the  cardiac  and  pulmonic  plexus ;  hence 
the  propriety  of  applications  to  the  spine ;  and  the  popular  opi- 
nion of  the  utility  of  a  Burgundy  pitch  plaster  between  the  shoul- 
ders, is  accounted  for,  from  anatomical  arrangement. 

1534.  Of  the  efficacy  of  the  change  of  residence,  more  parti- 
culary  to  the  country,  and  even  of  a  frequent  exposure  to  fresh 
air,  every  one  is  so  fully  persuaded,  that  the  remedy  is  abused, 
by  its  general  and  indiscriminate  adoption.     It  is  by  no  means 
uncommon  to  see  children  exposed,  in  the  coldest  and  most  in- 
clement seasons;  and  this  sometimes,  by  the  order  of  the  attend- 
ing physician.  Nothing  can  be  more  pernicious  and  ill  judged. 

1535.  On  the  subject  of  the  change  of  air,  Dr.  Watt  observes, 
p.  217,  "  I  agree  that  pure  air  and  change  of  air,  are  exceedingly 
necessary  to  bring  round  the  patient  from  a  convalescent  to  a 
confirmed  state  of  health;  but  this  is  not  the  only  period  in  which 
change  of  air  may  be  useful.     I  have  seen  the  disease  kept  re- 
markably mild  in  many  individuals,  and  in  several  large  fami- 
lies, by  having  the  children  almost  constantly  in  the  open  air 
from  the  commencement;  driving  them  about  from  place  to  place 
in  carts  and  open  carriages.  I  have  known  many  where  the  dis- 
ease was  very  severe,  on  being  taken  out  in  the  open  air,  getting 
better  every  hour  as  they  proceeded  on  their  journey,  the  patients 
scarcely  giving  a  cough,  and  the  fever  going  off  entirely." 

1536.  "It  must  be  confessed,  however,  that  on  many  occa- 
sions children  have  been  worse  on  being  freely  exposed  to  the 
open  air.     I  saw  several  remarkable  instances  of  it  last  winter 
and  spring.     Some  people,  who  had  formerly  experienced  the 
benefit  of  change  of  air,  were  anxious  to  give  it  a  trial,  without 
reflecting  sufficiently  on  the  nature  of  the  case,  and  season  of  the 
year."  p.  218. 

1537.  "  I  have  never  seen  children  in  any  state  of  the  disease, 
the  worse  for  being  taken  out  in  the  summer  months,  unless  too 
much  exposed  to  the  sun  in  the  middle  of  the  day,  or  to  the  cold 
damp  in  the  mornings  and  evenings."  p.  218. 

1538.  "The  great  question  then  appears  to  be,  what  are  the 
symptoms  which  most  mark  that  state  of  the  disease,  when  ex- 
posure will  be  useless  if  not  injurious?  To  which  I  would  reply, 
considerable  fever,  a  strong,  full,  and  frequent  pulse,  violent 
cough,  pain  in  the  breast,  and  above  all,  great  oppression  of 
breathing."  p.  221. 


PNEUMONIA,   OR    PERIPNEUMONIA.  445 

1539.  Dr.  Ferriar  is  of  opinion  that  soil  may  influence  the  sur- 
rounding atmosphere,  so  as  to  render  it  more  valuable  to  the  lungs 
in  hooping-cough;  he  instances  the  limestone  soil  of  Derbyshire, 
which  has  been  long  celebrated  for  the  cure  of  this  disease.*  Of 
this  we  can  say  nothing  from  our  own  experience. 

1540.  In  the  inflammatory  catarrh,  we  guard  against  cold,  by 
keeping  the  patient  in  a  room  duly  warmed ;  the  same  should  be 
observed  in  the  first  stage  of  hooping-cough.     The  lungs  in  this 
case  are  either  inflamed  or  peculiarly  susceptible  of  inflammation, 
so  that  the  slightest  exposure  brings  on,  renews,  or  violently 
exasperates  the  attack.     Catarrh,  or  active  pneumony  superin- 
duced on  pertussis,  constitutes  a  formidable  case,  and  most  fre- 
quently is  the  way  in  which  the  disease  proves  obstinate,  or  fatal. 
But,  the  inflammatory  stage  having  passed,  and  the  weather  mild, 
much  advantage  may  be  derived  from  gentle  exercise  in  the  open 
air — this  may  be  by  walking,  or  riding  in  a  carriage.  But  com- 
pletely to  eradicate  the  disease,  the  child  should  be  removed  into 
the  country,  provided  the  season  of  the  year  will  justify  the 
change. 

1541.  During  the  summer  months,  we  think  our  little  patients 
have  been  much  benefited  by  frequent  excursions  on  the  water, 
in  the  steam-boat,  and  we  constantly  recommend  this  mode  of 
exercise  when  the  weather  is  propitious. 

SECT.  VI. — PNEUMONIA,  OR  PERIPNEUMONIA. 

1542.  We  shall  under  this  head  confine  our  considerations  to 
an  inflammation  of  the  substance  of  the  lungs.  The  older  writers, 
indeed  almost  all,  from  Hippocrates  downwards,  comprehend 
under  the  .term  pneumonia  every  inflammatory  affection  of  the 
chest.     Hence,  pneumonia  has  been  divided  into  a  variety  of 
species,  as  the  seat,  kind,  and  degree  of  pain  may  exist — and 
thus  we  have  peripneumony,  pleurisy,  pericarditis,  paraphreni- 
tis,  &c. 

1543.  When  the  substance  of  the  lungs  was  the  seat  of  the 
inflammation,  the  disease  was  called  peripneumoniajt  when  it 

*  Med.  Hist,  and  Reflec.  Vol.  III.  p.  222. 

f  Both  Laennec  and  Andral  look  upon  peripneumonia  to  be  an  inflammation 
of  the  air-cells  of  the  lungs,  the  internal  surface  of  which  first  secretes  a  muco- 
sanguineous,  and  then  a  purulent  fluid.  Dr.  Williams  defines  peripneumony 
to  be  "an  inflammation  of  the  parenchyma  of  the  lungs."  We  very  much 
prefer  the  accounts  of  the  late  French  pathologists  of  this  disease,  to  any  of 
the  older  writers  on  this  subject,  or  indeed  we  might  say  of  the  modern;  for, 
until  Dr.  Forbes  and  Dr.  Williams'  works  made  their  appearance,  very  little 
advantage  had  been  taken  of  the  discoveries  in  pathology  by  the  French  school, 
by  the  British  physicians.  In  Wilson  Philip's  work  on  "  Sympathetic  Fever," 
the  names  of  Laennec  or  Broussais,  if  we  recollect  rightly,  are  not  even  men- 
tioned; we  are  altogether  at  a  loss  to  account  for  this. 


446  PNEUMONIA,    OR    PERIPNEUMONIA. 

occupied  the  pleura,  it  was  called  pleuritis;  when  the  heart  was 
the  besieged  organ,  it  was  called  carditis ;  when  the  diaphragm 
was  the  suffering  part,  it  was  called  paraphrenitis;  and  even  in- 
flammations of  the  mediastinum,  and  pericardium,  were  looked 
upon  as  entitled  to  separate  appellations.  Hence,  arose  names 
for  the  combinations  of  the  different  parts  that  might  be  labour- 
ing under  inflammation,  and  looked  upon  as  complications  of  dis- 
ease— such  was  the  origin  of  the  terms  pleuro-peripneumonia,  or 
peripneumo-pleuritis,  &c.  and  which  combinations  unquestiona- 
bly occasionally  exist. 

1544.  Doubtless,  the  inventors  of  these  divisions  thought  much 
was  gained  by  attempting  to  determine  the  seat  of  the  affection; 
though  modern  experience  does  not  seem  to  confirm  any  great 
practical  utility  in  an  accurate  location.     We  say  this  "attempt 
at  accurate  location  ;"  for  it  is  nothing  more ;  since  we  are  not  in 
possession  of  such  diagnostics  as  shall  free  the  subject  from  all 
uncertainty  as  regards  the  various  seats  of  inflammation,  within 
the  cavity  of  the  thorax.   Nor  is  this  perhaps  any  great  practical 
loss,  so  far  as  we  yet  understand  the  nature  of  inflammation,  or 
the  modes  of  subduing  it  in  the  various  tissues  it  may  affect; — 
for,  with  very  few  exceptions,  if  any,  they  are  treated  upon  the 
same  general  principles.     And  when  deviations  in  treatment 
were  thought  necessary,  they  are  founded  upon  the  nature  of 
certain  epidemic  causes,  the  force  of  the  disease,  or  some  consti- 
tutional peculiarity,  rather  than  upon  any  difference  in  the  in- 
flammation arising  from  the  particular  seat,  or  the  peculiar  tissue 
involved.  We  shall,  for  these  reasons,  confine  our  considerations 
more  particularly  to  the  history,  nature,  and  mode  of  cure  of 
pneumonia,  or  peripneumonia;  comprehending  under  this  term, 
as  observed  above,  inflammations  of  the  parenchyma  of  the  lungs; 
though  the  several  thoracic  viscera,  and  their  appendages,  will 
also  be  duly  considered.  We  shall  do  this,  not  because  we  expect 
to  gain  much  in  a  practical  point  of  view  during  the  active  stages 
of  the  disease;  but  because,  inflammation  of  the  separate  tissues 
give  rise  to  several  peculiar  pathological  phenomena,  which  are 
revealed  during  life  by  the  stethoscopej  and  confirmed  by  the 
knife  after  death. 

Causes  of  Pneumonia. 

1545.  This  complaint,  like  almost  all  the  phlegmasias,  may  be 
occasioned  by  the  sudden,  or  long-continued  application  of  cold, 
and  especially,  to  the  lower  extremities.  It  is  also  frequently  in- 
duced by  breathing  for  a  long  time  in  an  atmosphere  of  low  tem- 
perature, and  suddenly  exchanging  it  for  one  of  high  temperature, 
and  perhaps  the  reverse.     This  cause  operates  with  particular 


FNEtTMONIA,    OR   PERIPNEUMONIA.  447 

force  upon  delicate  females;  young  and  very  aged  persons,  and 
all  such  as  are  predisposed  to  pulmonic  affections. 

1546.  Exposure  to  cold  and  damp  when  not  exercising;  or 
immediately  after  exercise,  and  if  it  have  produced  perspiration. 
Wearing  of  damp  clothes;  wearing  garments  too  thin  for  the  sea- 
son, sleeping  in  a  damp  bed,  &c. 

1547.  Running,  very  fast  walking,  or  any  other  exercise  that 
will  very  much  increase  the  circulation  through  the  lungs,  espe- 
cially in  a  cold,  sharp  air.    Epidemic  influence  may  also  contri- 
bute to  the  production  of  pneumonia,  by  inducing  a  strong  pre- 
disposition; and  thus  rendering  slight,  occasional  causes  avail- 
ing— hence,  the  frequency  of  this  complaint,  as  an  epidemy.  The 
operation  of  this  last  cause  is  sometimes  sufficiently  whimsical — 
selecting  its  victims  at  one  time,  from  among  children,  or  very 
young  persons;  at  others,  those  more  advanced  in  life;  and  again 
only,  from  the  aged  and  infirm. 

1548.  As  a  general  rule  however,  the  sanguine  and  plethoric, 
are  most  frequently  selected ;  and  those,  at  about  the  middle  pe- 
riod of  life.  Dr.  Cullen  makes  the  time  later;  that  is,  from  forty- 
five  to  sixty. 

1549.  Other  causes  than  those  enumerated  have  been  assigned 
for  pneumonia;  but  of  their  agency  much  doubt  may  be  entertain- 
ed; such  as  acrid  vapours,  dust,  violent  coughing,  adhesions  o-f 
the  pleura,  &c.  &c. 

Symptoms  of  Pneumonia,  or  Peripneumonia. 

1550.  This  affection  as  well  as  several  others  that  some  have 
comprehended  under  this  term,  are  announced  by  the  same  ge- 
neral suite  of  symptoms;  indeed,  it  is  no  less  a  matter  of  uncer- 
tainty, than  it  may  be  of  indifference  in  a  practical  light,  on  what 
part  of  the  pulmonary  system,  the  disease  fixes  upon.     For 
wherever  the  inflammation  attaches  itself,  whether  it  be  the  sub- 
stance of  the  lungs,  or  to  any  one  portion  of  the  membrane  which 
covers  them,  or  any  other  of  the  thoracic  viscera,  we  find,  it  an- 
nounces itself,  by  the  usual  signs  of  phlegmasia?. 

1551.  A  sense  of  cold,  sometimes  a  well-marked  chill,  follow- 
ed by  heat,  together  with  pain  in  some  one  portion  of  the  thorax, 
are  the  initiatory  symptoms  of  pneumonia.     Cough,  hurried,  or 
difficult  breathing,  thirst,  and  anxiety  soon  follow.     The  pulse 
is  more  than  usually  frequent,  or  more  than  usually  slow,  and 
the  temperature  of  the  skin  is  almost  always  increased.     The 
pain  and  cough,  may  be  more  or  less  severe,  as  the  attack  may 
be  more  or  less  violent;  and  the  pulse  will  be  influenced  in  pro- 
portion; the  difficulty  of  breathing  will  augment,  as  the  disease 


448  PNEUMONIA,   OR   PERIPNEUMONIA. 

progresses.  Inspiration  is  imperfectly  performed,  ii> consequence 
of  the  increase  of  pain  which  an  attempt  to  fill  the  lungs  creates, 
and  hence  the  breathing  becomes  short  and  frequent.  Or,  if  there 
be  no  pain,  or  it  be  obtuse,  the  oppression  is  increased,  and  the 
breathing  becomes  laborious,  with  a  feeling  of  heaviness  about 
the  prsecordia.  But  Laennec  insists,  that  "the  crepitous  rattle 
is  the  pathognomonic  sign  of  the  first  stage  of  peripneumony." 
He  says,  "it  is  perceptible,  (by  the  stethoscope,)  from  the  very 
invasion  of  the  inflammation;  at  this  time  it  conveys  the  idea  of 
very  small  equal-sized  bubbles,  and  seems  hardly  to  possess  the 
character  of  humidity.  These  characters  are  most  marked  as  the 
inflamed  spot  is  near  the  surface  of  the  lungs,"  &c.*  p.  207.  An- 
dral  says  it  is  caused  by  the  intermixture  of  air  and  liquid  secre- 
tion in  the  air-cells. 

1552.  Position  influences  the  degree  of  pain;  sometimes  it  is 
augmented  by  lying  on  the  side  affected,  but  is  not  constantly 
so,  as  the  contrary  sometimes  obtains;  but  a  full  inspiration  is 
almost  always  attended,  by  an  increase  of  pain.     Sometimes,  the 
patient  suffers  less  when  he  lies  upon  his  back,  or  on  his  breast ; 
at  others  he  is  obliged  to  observe  an  erect  position. 

1553.  The  seat  of  pain  is  not  constantly  the  same — some- 
times it  may  occupy  either  side;  at  others  the  sternum;  or  it 
may  dart  backwards  towards  the  scapulae,  or  be  confined  under 
one.     It  is  more  usual  however,  about  the  sixth  or  seventh  rib, 
and  nearly  midway  between  the  spine  and  sternum.     Nor  is  it 
always  stationary;  we  have  seen  it  wander  occasionally  to  almost 
every  portion  of  the  chest. 

1554.  The  character  of  the  pain,  either  in  degree  or  in  kind, 
is  by  no  means  constant  or  uniform ;  it  is  exquisitely  acute  and 
severe  sometimes;  especially  during  inspiration,  and  coughing; 
at  other  times,  it  is  obtuse,  obscure,  or  even  wanting ;  we  have 
seen  cases/especially  in  children,  manifest  not  the  least  suffering 
either  during  the  act  of  coughing,  or  of  drawing  a  full  breath; 
nor  was  there  in  two  cases  we  witnessed  lately,  the  slightest 
dyspnoea,  though  the  post  mortem  examinations  proved  the  ex- 
istence of  great  previous  inflammation ;  for  there  was  not  only 
extensive  adhesions,  but  considerable  hepatization,  in  both  in- 
stances.    In  one,  the  lungs  were  frequently  and  severely  exer- 
cised to  the  last  moment,  by  hooping-cough;  and  the  other  by 
an  obstinate  cough,  the  consequence  of  recent  measles.     Pain 
therefore  is  not  a  constant  attendant  on  pneumonia;  nor  does  its 

*  We  have  inserted  this  much  of  the  stethoscopic  observations  of  Laennec, 
(the  whole  being  too  long,)  merely  to  direct  the  attention  to  this  new  and 
highly  important  mode  of  ascertaining  the  condition  of  the  lungs,  to  the  whole 
class  of  medical  practitioners. 


PNEUMONIA,    OR    PERIPNEUMONIA.  449 

location  by  any  means,  decide  the  nature  of  the  tissue,  in  which 
the  inflammation  may  exist. 

1555.  This  absence  of  pain,  has  not  unfrequently  led  the  prac- 
titioner into  error  as  regards  the  real  nature  of  the  disease  he 
was  about  to  treat ;  for  he  sometimes  founds  his  diagnostic  of 
pneumonia,  upon  its  presence.     Indeed,  with  many,  a  pain  in 
the  side  is  essential  to  the  existence  of  this  complaint — and  the 
left  side  is  the  chosen  spot;  and  if  pain  be  not  there,  the  disease 
is  not  pneumonia.     But  this  opinion,  however  extensive  and 
popular,  must  be  looked  upon  as  a  vulgar  error ;  for  writers  of 
the  best  information  declare  the  right  side  to  be  more  frequently 
involved,  than  the  left. 

1556.  Thus  Laennec  informs  us,  (p.  200,)  that  "the  right  lung 
is  more  frequently  affected  than  the  left,  not  only  in  cases  of 
pneumonia,  but  in  almost  all  the  other  morbid  affections  to  which 
these  organs  are  subject."     Morgagni  declares  the  same  thing. 
And  Aridral*  says,  "  that  out  of  two  hundred  and  four  cases  of 
well-marked  pneumonia,  the  right  lung  was    affected    in   one 
hundred  and  twenty-one,  the  left  in  fifty-eight,  and   both  in 
twenty-five."     To  these  authorities  however  we  may  oppose  M. 
Lombard,!  who  found,  that  of  nine  hundred  and  sixty-eight  pa- 
tients afflicted  with  pneumonia,  four  hundred  and  thirteen  felt 
the  pain  in  the  right  side.     For  this  peculiarity  of  location,  a 
number  of  conjectures  have  been  offered,  but  none  satisfactory. 

1557.  Cough,  to  a  greater  or  less  extent,  is  an  almost  constant 
attendant  in  pneumonia.  In  the  commencement  however,  when 
the  attack  is  both  sudden  and  severe,  we  have  sometimes  known 
this  symptom  absent,  and  suppressed,  and  sometimes  would  not 
appear,  until  the  patient  had  been  amply  bled.     It  will  then  de- 
clare itself  with  both  severity,  and   pertinacity.     In  the  early 
stage  of  pneumonia,  the  cough  is  rarely  attended  by  expectora- 
tion, if  the  inflammation  be  severe,  and  the  febrile  symptoms  run 
high.     And  the  force  of  the  disease  may  in  some  instances  be 
almost  determined  by  the  extent,  and  period  at  which  spitting 
may  commence.  In  mild  cases  it  begins  as  a  general  rule  earlier, 
than  in  the  severer;   and  in  the  latter  we  have  known  this  dis- 
charge to  keep  away  even  for  several  days,  or  until  the  force  of 
the  disease  had  been  weakened  by  several  blood-lettings  and 
other  evacuations ;  while  in  the  former,  it  has  become  abundant 
in  twenty-four  or  thirty-six  hours. 

1558.  More  or  less  relief  is  almost  sure  to  be  experienced, 
when  cough  is  accompanied  by  spitting;  but  much  depends  upon 
the  nature  of  this  discharge.   It  is  usually  thin  in  the  beginning ; 

•  CL  Med.  Tom.  II.  p.  317.     •      f  Archives  Generales,  Janvier,  1831. 

57 


450  PNEUMONIA,    OR    PERIPNEUMONIA. 

but  acquires  consistency  as  the  disease  proceeds.*  When  the 
sputa  are  pretty  thick,  copious,  easily  discharged  from  the  lungs, 
mild,  white  or  slightly  yellow,  they  may  be  looked  upon  as  fa- 
vourable. On  the  other  hand,  a  tenacious,  gluey  expectoration 
is  unfavourable;  and  is  decidedly  bad,  when  the  matter  discharged 
is  thin,  acrid,  excoriating,  of  a  brown  or  greenish  colour ;  and 
especially  if  sanious  and  fetid.  Mucus  tinged  with  blood,  is  by 
some  considered  a  favourable  sign — we  are  inclined  ourselves  to 
this  belief;  it  certainly  cannot  of  itself  be  looked  upon  as  unfa- 
vourable, while  the  other  portions  of  the  sputa  are  favourable  in 
their  appearance ;  and  especially,  if  they  be  delivered  into  the 
mouth  without  much  rattling  noise  in  the  lungs.  The  sputa  must 
be  considered  as  representing  the  condition  of  the  secreting  por- 
tions of  the  bronchia,  and  the  general  state  of  the  pulmonary  cir- 
culation ;  therefore  the  prognosis  will  very  much  depend  upon 
the  appearance  of  the  expectoration,  and  the  nature  and  degree 
of  the  cough. 

Prognosis. 

1559.  The  degree  of  relief  that  expectoration  affords,  will  aid 
us  in  our  prognosis;  this  is  even  a  more  certain  sign  than  the  ap- 
pearance of  sputa  individually  considered ;  for  if  they  afford 
freedom  and  ease  to  the  chest,  it  is  a  favourable  sign,  be  the  sputa 
of  what  colour  they  may.   While  on  the  other  hand,  if  the  lungs 
find  no  comfort  from  the  expectoration,  its  colour  or  consistence 
signifies  but  little.     If  the  expectoration  should  become  very 
sparing,  or  has  been  absent  from  the  beginning;  or  if  it  be  alto- 
gether arrested  after  it  has  been  established,  it  is  sure  to  proclaim 
a  continuance,  or  an  increase  of  mischief,  if  not  a  state  of  immi- 
nent danger.     But  on  the  other  hand,  if  it  return,  and  be  of  fa- 
vourable appearance,  it  marks  a  diminution  of  disease,  if  it  do  not 
declare  a  freedom  from  danger. 

1560.  But  the  state  of  the  disease,  or  the  degree  of  its  danger, 
are  not  portended  by  the  sputa  alone;  other  marks  must  be  taken 

*  Laennec  says,  "  the  expectoration  in  a  great  many  instances  has  an  ap- 
pearance quite  characteristic,  and  which,  in  my  opinion,  may  in  itself  enable 
us  to  recognise  the  disease;  as  I  have  never  met  with  it  in  any  other.  These 
sputa,  which  I  shall  term  glutinous  or  pneumonic,  when  received  into  a  flat 
and  open  vessel,  unite  in  so  viscid  and  tenacious  a  mass,  that  we  may  turn  it 
upside  down,  even  when  full,  without  the  sputa  being  detached,  although  they 
may  hang  from  the  vessel's  mouth.  If  we  shake  the  vessel  its  contents  vibrate 
like  jelly,  but  less  so.  The  colour  of  this  expectoration  is  frequently  some 
shade  of  red,  particularly  that  of  rust;  or  it  is  sea-green,  tawny,  orange,  saffron, 
yellowish,  or  a  dull  green."  "  If  sputa  of  this  kind  existed  constantly  in  peri- 
pneumony,  we  should  require  no  other  sign  to  indicate  its  presence."  p.  215. 


PNEUMONIA,    OR    PERIPNEUMONIA.  451 

into  consideration;  and  first,  the  state  of  the  circulating  system. 
We  have  already  remarked,  that  fever  was  present  as  an  initial 
symptom;  that  is,  it  became  evident  as  soon  as  the  local  condition 
of  the  lungs  was  established,  and  even  perhaps  before  the  affec- 
tion of  these  organs  betrayed  itself,  by  other  symptoms.* 

1561.  Much  therefore  must  depend  upon  the  degree  and  cha- 
racter of  the  accompanying  fever.     If  this  be  high,  and  of  diffi- 
cult reduction  by  proper  means,  it  increases  the  risk  from  the 
disease ;  because  it  always  declares  the  extent  and  force  of  the 
local  affection.     On  the  other  hand,  when  fever  becomes  obe- 
dient to  the  influence  of  remedies,  it  declares  that  the  original 
affection  is  abating,  and  giving  promise  of  future  improvement. 

1562.  The  pulse  therefore  must  be  no  inconsiderable  guide 
during  the  whole  progress  of  the  disease.   For  the  most  part,  the 
pulse  is  frequent,  tense  and  strong,  in  the  beginning  of  pneumonia. 
But,  if  the  disease  has  been  sudden  and  violent  in  its  attack,  the 
pulse  may  not  possess  these  characters;  it  may  be  corded,  creeping, 
slow,  contracted,  and  very  resisting:  this  is  the  oppressed  pulse 
of  authors  ;  and  it  always  changes  its  character  by  a  bleeding  of 
sufficient  extent,  into  a  softer,  fuller,  and  more  distinct  pulse. 
(See  note  to  par.  352. )  The  young  practitioner  is  warned  not  to 
mistake  this  pulse  for  a  "really  depressed,  or  exhausted  pulse." 
The  latter  has  none  of  the  characters  of  the  oppressed  pulse,  if 
we  except  size.     It  is  frequent,  small,  and  unresisting. 

1563.  On  this  head,  Laennec  furnishes  us  with  several  valuable 
practical  remarks ;  remarks  which  should  be  well  remembered 
by  every  practitioner.  "  In  every  case"  (of  pneumonia,  whether 
simple  or  complicated,)  "  whatsoever,  the  more  feeble  the  pulse 
is,  the  less  indication  is  there  for  venesection.    At  the  same  time, 
it  is  well  known  to  every  practitioner  that  this  feebleness  is 
sometimes  only  apparent,  and  that  bleeding  will  render  the  pulse 
both  stronger  and  fuller.    To  discriminate  the  false  from  the  real 
feebleness  of  pulse,  requires  the  tact  of  an  experienced  practi- 
tioner; and  unfortunately  the  most  expert  are  in  this  often  de- 
ceived.    In  cases  of  this  kind,  the  use  of  the  stethoscope  will 
tend  greatly  to  remove  our  doubts."     "I  shall  observe,  that 
whenever  the  pulsations  of  the  heart  are  (proportionally)  much 
stronger  than  those  of  the  arteries,  we  may  bleed  without  fear, 
and  with  the  certainty  of  finding  the  pulse  rise ;  but  if  the  heart 

*  "  The  fever  in  peripneumony  is  truly  symptomatic;  that  is  to  say,  is  the  ef- 
fect of  the  inflammation.  It  rises  and  falls  with  the  inflammatory  orgasm.  It 
very  frequently  happens  that  as  soon  as  this  latter  is  checked  by  the  lancet  or 
otherwise,  the  fever  ceases  entirely,  although  the  perfect  resolution  of  the  pul- 
monary engorgement  will  not  be  accomplished  in  less  than  a  fortnight,  three 
weeks,  or  even  a  month." — Laennec,  p.  218. 


452  PNEUMONIA,  OR    PERIPNEUMONIA. 

and  pulse  are  both  weak,  the  detraction  of  blood  will  almost 
always  occasion  complete  prostration  of  strength."  p.  243. 

1564.  We  have  never  witnessed  the  peculiarity  in  the  pulse 
of  the  two  arms  in  pneumonia,  as  mentioned  by  Cleghorn  and 
others ;  namely,  that  it  is  more  obscure  on  the  side  affected,  or 
that  it  differs.     We  have  sought  for  it  in  a  number  of  instances, 
but  have  never  been  satisfied  of  its  existence,  though  the  cases 
in  which  we  tried  to  detect  it,  were  strongly  marked.     We  are 
disposed  to  believe,  that  some  accidental  circumstance  may  have 
produced  the  differences  spoken  of,  without  their  being  imposed 
by  the  disease  itself.     There  is  almost  always  a  difference  in  the 
force  and  size  of  the  artery  in  the  two  wrists  of  every  body,  de- 
pending almost  altogether  upon  the  different  degrees  of  use  to 
which  the  arms  are  subjected — thus,  the  right,  in  all  right-handed 
people,  is  fuller  and  stronger  than  the  left,  and  vice  versa ;  and 
this  may  account  for  the  observation  of  Zimmerman  and  others, 

1565.  The  skin  is  almost  always  hot  and  dry,  but  it  is  not 
uniformly  so — the  contrary  of  this  was  lately  observed  in  a  very 
strongly-marked  case,  and  which  terminated  fatally  on  the  se- 
venth day.     The  whole  surface  of  the  body  was  moist  from  the 
very  commencement  of  the  disease  to  its  final  termination,  though 
a  severe  diarrhoea  attended  for  the  last  thirty-six  hours  before 
death.     The  face  is  hectically  flushed,  and  sometimes  covered 
with  a  dripping  sweat,  especially  the  upper  lip  and  forehead. 

1566.  The  urine  for  the  most  part  is  sparing  and  high-colour- 
ed in  the  beginning ;  altering,  if  the  disease  proceed  favourably, 
to  a  more  copious,  and  to  a  less  intense  tone ;  or  if  the  disease 
augment  in  danger,  it  may  be  discharged  in  large  quantities,  and 
this  quite  limpid. 

1567.  The  absolute  state  of  the  bowels,  is  rather  difficult  to 
determine,  as  cathartic  medicines  are  constantly  had  recourse  to 
in  the  very  commencement  of  the  disease — it  may  however  be 
observed,  that  they  are  either  very  difficult,  or  unnaturally  easy 
to  move.    In  the  first  case,  we  are  under  the  necessity  of  almost 
constantly  urging  them  by  laxatives,  while  in  the  other  a  diar- 
rhoea may  supervene  on  the  first  dose  of  medicine.     For  the 
most  part,  the  discharges  have  nothing  peculiar  in  them,  unless 
they  are  influenced  by  an  epidemic  cause,  or  some  peculiarity  of 
constitution. 

1568.  The  thirst  for  the  most  part  is  urgent,  and  especially 
for  very  cold  drinks  and  light  acids.     The  tongue  is  moist  and 
furred  with  a  white,  pretty  dense  coat  in  the  beginning,  but 
changes  to  yellowish-brown,  and  becomes  sometimes  dry,  espe- 
cially if  the  expectoration  is  very  limited,  and  not  of  a  good  cha- 
racter.    In  this  case,  a  tenacious  ropy  saliva  is  secreted,  which  is 


PNEUMONIA,   OR    PERIPNEUMONIA.  453 

not  easily  detached,  and  extends  itself  into  threads  or  filaments, 
when  the  mouth  is  opened,  or  when  the  tongue  is  protruded. 
The  brain  is  not  generally  affected  by  delirium,  though  there  is 
a  more  than  usual  disposition  to  sleep,  if  the  disease  assume  a 
menacing  character.  This  sometimes  is  so  considerable,  and  the 
cough  is  so  long  suspended,  that  the  rattling  in  the  throat  is 
very  audible,  in  consequence  of  the  augmented  accumulation  of 
phlegm,  which  at  length  becomes  so  excessive,  as  to  rouse  the 
patient  by  a  severe  coughing  fit  to  discharge  it. 

1569.  When  pneumonia  terminates  favourably,  it  is  by  reso- 
lution ;*  this  disposition  is  announced,  by  the  pulse  becoming 
less  frequent,  or  irritated,  softer,  and  more  expanded  and  com- 
pressible.    By  the  skin  sending  a  free,  warm  perspiration  on 
every  part  of  the  body;  by  the  flush  disappearing  from  the  cheek; 
by  the  urine  becoming  more  abundant  and  depositing  a  lateritious 
sediment. t  By  the  cough  abating  both  in  severity  and  frequency; 
and  by  its  being  followed  by  a  copious,  purulent-looking  mucus. 
By  the  tongue  beginning  to  clean;  by  the  abatement  of  thirst, 
and  the  drowsy  disposition  being  exchanged,  for  one  of  greater 
watchfulness.     By  the  breathing  being  free  and  unattended  by 
pain;  and  when  a  moderate  spontaneous  diarrhoea  takes  place. 

1570.  On  the  other  hand,  the  prognosis  will  be  unfavourable, 
when  the  pulse  becomes  both  weaker  and  more  frequent,  and 
not  resisting  the  slightest  pressure  of  the  finger.    When  the  skin 
pours  out  sweat,  which  is  not  quickly  followed  by  relief;  when 
the  hands  and  feet  are  dripping  with  moisture,  and  are  at  the 
same  time  deathly  cold.     When  the  flush  on  the  cheek  assumes 
a  livid,  or  mahogany  colour;  and  the  lips  become  blue.     When 
the  urine  is  pale  and  very  abundant;  very  sparing  and  intense  in 
colour ;  or  is  entirely  suppressed.     When  the  cough  is  nearly, 
or  entirely  suspended,  as  well  as  the  expectoration ;  or  when  the 
former  becomes  almost  incessant,  and  is  accompanied  with  a 
gluey  or  sanious  sputa,  or  by  blood  itself  in  considerable  quantity. 
When  the  tongue  becomes  rough,  dry,  and  dark-coloured,  and 
the  breath  fetid.     When  delirium^  or  coma  supervenes,  and  a 

*  "  When  resolution  takes  place,  the  crepitous  rattle  becomes  daily  less  per- 
ceptible, while  the  natural  sound  of  respiration  becomes  gradually  more  dis- 
tinct, and  at  last  is  heard  alone." — Laennec,  p.  211. 

t  "  Peripneumonia  frequently  terminates  favourably  by  a  distinct  crisis,  not 
only  in  the  cases  where  the  mildness  of  the  attack  or  ignorance  of  its  charac- 
ter, have  occasioned  the  disease  to  be  left  to  the  unassisted  efforts  of  nature, 
but  even  when  repeated  venesections  had  been  employed  without  any  benefit. 
The  most  common  of  the  critical  evacuations  is  a  lateritious  or  white  sediment 
in  the  urine?  and  we  should  distrust  any  other  unless  tflis  also  occurs  at  the 
same  time."— Laennec,  p.  219. 

+  "When  the  determination  of  the  blood  to  the  head  is  very  great,  and 
marked  by  coma  in  the  beginning  of  the  disease,  as  often  is  the  case  in  old  peo- 
ple of  a  plethoric  habit,  the  symptom  is  extremely  unfavourable,  as  the  pa- 


454  PNEUMONIA,    OR    PERIPNEUMONIA. 

constant  guggling  noise  is  made  by  both  inspiration  and  expira- 
tion, within  the  trachea  and  bronchia. 

1571.  Pneumonia  may  terminate  in  other  ways  than  resolu- 
tion ;  namely,  by  hepatization,*  suppuration,!  or  gangrene.^ 

Anatomical  Characters  of  Pneumonia. 

1572.  The  appearances  after  death  of  the  lungs  and  its  ap- 
pendages, vary  in  phenomena,  as  the  disease  may  have  been  of 
longer  or  shorter  duration.     Laennec,  whose  researches  into  the 
nature  of  the  affections  of  the  chest,  have  been  no  less  extensive 
than  successful,  makes  three  degrees  or  stages,  which  he  assures 
us  are  very  distinctly  marked,  and  easily  recognised  by  the  ap- 
pearances of  the  lungs ;  and  as  we  have  every  reliance  on  his 
fidelity  and  accuracy,  we  shall  follow  his  account  closely,  though 
very  briefly;  as  it  would  not  comport  with  the  plan  of  the  pre- 
sent work,  to  be  more  diffuse. 

tients  in  whom  it  occurs  usually  die  before  hepatization  is  completely  esta- 
blished; or  the  inflammation  reaches  the  stage  of  purulent  infiltration  in  the 
space  of  a  few  hours.  A  furious  delirium  is  a  much  less  dangerous  symptom." — 
Laennec,  p.  217. 

"  The  general  opinion  of  writers  is,  that  delirium  is  an  extremely  dangerous 
symptom.  It  is  stated  by  Cullen,  Frank,  &c.  Lommius  says,  (Obs.  Med.  Lib. 
secund,  p.  186,)  'Potissimum  lethalis  est  cum  insanium  movit.'  I  remember 
the  late  Dr.  Gregory  to  have  stated  in  his  lectures,  that  he  had  only  known 
one  patient  recover  who  had  delirium." — Note  by  Dr.  Forbes,  p.  217. 

*  "  In  this  degree  the  lung  has  entirely  lost  its  crepitous  feel  under  the  fin- 
ger, and  has  acquired  a  consistency  and  weight  altogether  resembling  those  of 
liver."  Ib.  p.  197.  "  This  change,"  (hepatization,  of  Laennec,  and  the  ramol- 
lissement  rouge  of  Andral,)  "consists  in  the  effusion  of  a  semi-solid  albumen 
in  the  interstitial  tissues,  and  which  pressing  on,  and  obliterating  the  cavities 
of  the  air-cells  and  smaller  bronchi,  destroys  the  spongy  structure  of  the  lung, 
and  converts  it  into  a  solid  mass.  A  hepatized  lung  presents  the  following 
character  after  death — externally  it  is  of  a  deep  red  colour,  which  internally  is 
mottled  with  a  number  of  small,  light  yellowish  granular  spots,  with  patches 
of  whiter  colour,  marking  the  vessels,  membranous  septa,  &c.  not  affected  by 
the  inflammation.  It  sinks  in  water,  and  is  no  longer  crepitant,  but  breaks 
readily  under  the  fingers,  and  may  by  a  slight  pressure,  be  reduced  ta  a  red- 
dish pulp."—  Williams,  p.  82. 

f  "  Notwithstanding  the  opinion  of  the  ancients,  and  the  common  notions  of 
the  mere  practical  physicians  of  the  present  day,  respecting  pulmonary  ab- 
scesses, which  are  generally  termed  vomicae,  it  is  certain,  there  is  no  organic 
lesion  more  uncommon,  than  a  real  collection  of  pus  in  the  substance  of  the 
lungs."  Ib.  p.  200. 

$  "This  is  a  rare  disease.  It  can  scarcely  be  ranged  among  the  terminations 
of  the  pulmonary  inflammation,  and  still  less  can  it  be  considered  as  a  conse- 
quence of  its  intensity;  since  we  find,  in  cases  of  this  kind,  the  inflammatory 
character  very  slightly  marked,  as  well  in  regard  of  the  symptoms,  as  of  the 
engorgement  of  the  pulmonary  substance."  Ib.  p.  221. 


PNEUMONIA,  OR    PERIPNEUMONIA.  455 


First  Degree,    (Obstruction.) 

1573.  This  stage  is  marked  by  the  external  livid  or  violet 
hue  of  the  lung  and  its  increase  of  density.     It  is  however  cre- 
pitous,  in  a  degree ;  and  if  the  lung  be  pressed  between  the  fin- 
gers, a  fluid  is  perceived.     It  retains  the  pressure  of  the  finger 
like  an  cedematous  limb.     When  cut  into,  it  is  of  a  livid  blood 
colour;  injected  by  a  frothy  serous  fluid,  more  or  less  bloody, 
which  flows  from  it  abundantly.     The  spongy  texture  is  how- 
ever to  be  still  observed,  unless  in  some  more  impacted  points.* 

Second  Degree,  (Hepatization.) 

1574.  No  crepitus  to  be  observed;  the  lung  has  acquired  the 
weight  and  consistence  of  liver.     The  lungs  are  frequently  less 
livid  externally  than  in  the  first  degree;  internally  the  redness 
is  more  or  less  deep;  and  differs  from  a  violet-gray  to  blood-red. 
When  the  lung  is  cut,  hardly  any  fluid  escapes;  but  a  small  quan- 
tity of  bloody  serum  may  be  forced  out  by  scraping  the  cut  sur- 
face with  a  scalpel,  which  is  thicker  than  that  of  the  first  de- 
gree. When  the  cut  surface  is  exposed  between  the  eye  and  the 
light,  no  cellular  appearance  presents  itself;  a  granular  aspect 
shows  itself  instead.  This  account  is  confirmed  by*Dr.  Williams 
in  his  work,  note,  p.  18. 

Third  Degree,  (Purulent  Infiltration.) 

1575.  In  this  degree  the  lung  has  some  hardness,  and  the  above 
granular  appearance  shows  itself,  but  is  of  a  yellowish-pale  orstraw 
colour.  The  pus  at  first  as  it  begins  to  form,  appears  in  small  de- 
tached yellow  points.  These  gradually  combine,  and  the  whole 
lung  finally  assumes  a  uniform  straw  or  lemon  colour,  and  when 
incised,  yields  a  viscid  purulent  matter,  which  sometimes,  espe- 
cially in  children,  or  young  persons,  is  of  a  fine  whitish-yellow 
colour.     The  lungs  may  show  evidences  of  the  three  degrees  of 
inflammation  at  one  and  at  the  same  time.  The  lower  parts  of  the 
lungs  are  those  most  commonly  occupied  by  peripneumony ;  and 
when  the  disease  involves  the  whole  viscus,  it  is  almost  always 
in  the  inferior  part  that  it  commences.    When  the  three  degrees 

*  "  Our  knowledge  of  minute  anatomy  does  not  permit  us  to  specify  with 
certainty  the  exact  and  essential  seat  of  this  inflammation;  but  I  am  disposed, 
from  a  consideration  of  the  signs,  and  the  effects  upon  the  tissue,  to  refer  it 
principally  to  the  plexus  of  vessels  and  sub-mucous  tissue  surrounding  and 
uniting  the  minute  extremities  of  the  bronchi." — Williams,  p.  80. 


456  PNEUMONIA,   OR    PERIPNEUMONIA. 

exist  in  different  parts  of  the  same  lung,  the  sight  of  the  more  ad- 
vanced stage  is  usually  in  the  same  inferior  portion.* 

1576.  The  whole  of  both  lungs  is  never  found  inflamed  in  the 
third  or  even  in  the  second  degree;  and  this  for  obvious  reasons; 
since  an  obstruction  of  this  kind  could  not  take  place  instanta- 
neously, and  must  render  respiration  impossible.     But  it  is  by 
no  means  uncommon  to  meet  with  cases  in  which  one  whole  lung 
and  more  than  half  the  other  is  quite  impervious  to  air.    It  is  in 
the  resolution,  or  in  the  retrogression  of  these  several  conditions 
of  the  lungs,  that  the  stethoscope  becomes  so  highly  useful.     By 
it  the  various  grades  of  the  degrees  of  increase,  or  diminution, 
can  be  detected,  it  would  seem,  with  positive  certainty;  but  per- 
haps more  especially  in  the  first,  agreeably  to  Dr.  Williams,  p. 
85.     He  says, 

1577.  "It  is  in  the  first  stage  of  inflammatory  injection  that  aus- 
cultation proves  pre-eminently  useful,  in  assuring  us  of  the  exist- 
ence of  a  disease  that  no  other  symptom  could  discover.     The 
presence  of  the  ronchus  crepitans  may  be  taken  as  a  warning  to 
resort  to  energetic  antiphlogistic  measures,  which  in  this  stage 
will  seldom  fail  in  arresting  its  course.     The  disappearance  of 
this  sign,  and  sometimes  the  presence  of  the  bronchial  respira- 
tion and  rhonchus,  announce  the  increasing  danger  and  progress 
of  the  disease,  as  they  indicate  its  advance  to  the  second  stage. 
The  diseased  structure  however  is  still  susceptible  of  a  return  to 
the  healthy  state,  and  the  view  we  have  taken  of  the  morbid 
anatomy  of  this  stage,!  suggests,  in  addition  to  means  directed 

*  "  This  changes  the  colour  of  the  diseased  lung  from  the  red  hepatization 
to  discoloured  yellow  or  brownish,  which  is  frequently  mottled  with  red  por- 
tions in  the  second  stage,  and  with  the  black  pulmonary  matter.  This  is  called 
by  Andral  ramollissement  gris.  The  tissue  is  quite  impermeable  to  air,  and  of 
extreme  friability,  being  reducible  by  slight  pressure  intoakindofpurilage." — 
Williams,  p.  84. 

f  Dr.  Williams'  observations  upon  the  physical  changes  of  the  diseased  parts, 
while  undergoing  resolution,  are  no  less  interesting  than  instructive.  He  says, 
p.  86,  "the  resolution  or  retrogression  of  peripneumonic  inflammation,  is  at- 
tended by  a  succession  of  the  same  physical  signs  that  marked  its  progress,  but 
in  an  inverted  order.  Thus  in  a  spot  where  no  sound  of  the  ingress  or  egress 
of  air  has  been  heard,  or  perhaps  only  a  bronchial  respiration,  a  slight  crepi- 
tant  ronchus  begins  to  be  distinguished  at  the  end  of  each  inspiration,  appa- 
rently occasioned  by  the  air  again  gaining  a  straightened  admission  through  a 
few  of  the  bronchial  tubes,  whose  calibres  have  been  partially  restored  by  the 
reabsorption  of  matter  round  their  parietes.  This  sign  increases  in  intensity 
as  the  resolution  proceeds;  the  broncbophony  and  bronchial  respiration  are 
diminished  as  the  lung  reacquires  its  spongy  structure,  and  becomes  a  worse 
conductor  of  sound.  After  a  while  the  natural  respiratory  murmur  is  heard 
mixed  with  the  crepitant  ronchus;  and  as  the  texture  becomes  more  permeable 
to  the  air,  this  increases,  as  that  diminishes,  and  the  healthy  function  of  the 
lung  is  thus  gradually  restored.  And  here  again  the  signs  obtained  by  auscul- 
tation are  invaluable,  as  they  alone  indicate  the  absence  of  the  disease.  The 


PNEUMONIA,    OR    PERIPNEUMONIA.  457 

against  the  inflammatory  orgasm,  the  important  advantage  with 
which  rubefacients  may  be  used." 

Treatment  of  Pneumonia. 

1578.  The  essential  character  of  pneumonia,  as  declared  by 
its  symptoms,  and  revealed  by  post  mortem  examinations,  is  a 
high  and  rapidly  disorganizing  inflammation  of  the  substance  of 
the  lungs.  Upon  this  subject,  the  opinions  of  all  practical  writers 
appear  to  be  concurrent,  if  we  admit  the  occasional  exceptions, 
produced  by  epidemic  influence.     And  perhaps  there  is  no  one 
disease  that  attacks  the  human  body,  in  the  treatment  of  which 
there  is  so  much  coincidence.  This  we  look  upon  as  a  most  for- 
tunate agreement,  both  for  the  patient  and  the  physician  ;Jbr,  to 
the  former,  it  secures  the  advice  and  experience  of  a  vast  num- 
ber of  men  of  great  professional  character;  while  it  relieves  the 
latter  from  all  that  perplexing  embarrassment  consequent  upon 
conflicting  opinions.    We  shall  on  this  account  proceed  with  the 
details  of  practice  with  the  more  confidence ;  as  what  we  shall 
say  upon  the  subject  of  others'  opinions  in  the  treatment  of  pneu- 
monia, so  entirely,  in  most  instances,  comports  with  our  own 
experience. 

1579.  The  principal  remedies  employed  for  the  cure  of  pneu- 
monia are,  1.  Blood-letting,  both  general  and  local.    2.  General 
evacuants.    3.  Blistering.    4.  Alteratives.    5.  Tonics.    6.  Large 
doses  of  emetic  tartar. 

1.  Of  Blood-letting,  Sf-c. 

1580.  This  remedy  in  pneumonia,  must  be  looked  upon  as 
one  of  indispensable  necessity;  and  though  this  be  admitted  by 
every  body,  yet  the  quantity  to  be  drawn,  and  the  frequency  of 
its  repetition,  is  by  no  means  so  unanimously  settled.     We  are 
averse  to  directions  upon  this  point,  when  the  quantity  is  to  be 
expressed  by  the  number  of  ounces  ;>  as  this  must  always  be  of 
uncertain  application,  as  no  two  cases,  perhaps,  will  require  the 
same  quantity,  precisely.  Constitution,  force  of  the  disease,  age, 
period  of  the  disease,  habit  with  respect  to  bleeding,  and,  epide- 
mic agency,  have  an  influence  upon  the  necessity  and  extent  of 
this  operation. 

dyspnoea  may  have  been  removed,  the  cough  may  have  ceased,  the  expectora- 
tion may  have  become  simply  catarrlial,  the  pulse  natural,  and  all  febrile  symp- 
toms disappeared;  and  yet  the  auscultator  detects  the  lurking  disease  in  the 
persistence  of  the  crepitant  ronchus;  and  .as  long  as  this  continues,  a  slight  ex- 
posure to  cold,  or  a  trivial  departure  from  antiphlogistic  regimen,  may  cause  a 
relapse,  which  in  a  subject  already  reduced  by  depletion,  may  be  more  diffi- 
cult to  cure  than  the  original  disease." 

58 


458  PNEUMONIA,   OR   PERIPNEUMONIA. 

1581.  On  this  account,  we  very  much  prefer,  that  the  quan- 
tity to  be  drawn  should  be  regulated  by  the  state  of  the  pulse  in 
particular,  and  on  the  immediate  condition  of  the  disease.     For 
if  we  do  not  regulate  the  operation  by  these  rules,  much  uncer- 
tainty must  exist;  if  absolute  risk  be  not  incurred.     Besides,  if 
we  make  the  pulse,  and  the  condition  of  the  part,  as  they  may 
be  affected  by  this  operation  the  rule,  we  shall  avoid  much  em- 
barrassment in  the  abstraction  of  blood,  either  as  regards  the 
quantity  to  be  drawn,  the  necessity  of  its  repetition,  and  the  pro- 
priety of  drawing  it  at  any  period  of  the  disease. 

1582.  As  regards  the  pulse,  too  much  attention  cannot  well 
be  paid  to  its  varying  state,  both  as  respects  the  consequences  of 
disease,  and  the  influence  of  remedies,  in  all  affections  of  high 
excitement,  and  of  rapid  course.   For  in  employing  the  only  re- 
medy capable  of  controlling  their  force,  or  of  abridging  their 
career,  namely,  blood-letting,  we  do  nothing,  unless  we  abstract 
a  sufficient  quantity  to  give  immediate  relief  to  the  affected  part — 
and  this  cannot  be  determined  by  prescribing  the  loss  of  any 
given  number  of  ounces  of  blood,  as  the  quantity  that  may  afford 
relief  in  one  instance,  may  be  altogether  insufficient  in  another, 
or  in  a  third,  it  may  be  even  excessive  and  injurious.     On  this 
account,  we  are  in  the  habit  of  taking  as  much  blood  as  will  re- 
lieve the  pain,  oppression,  or  sensation  of  congestion  in  the  chest. 
This  is  to  be  determined  by  requesting  the  patient  to  make  as 
full  an  inspiration  as  he  can  from  time  to  time  during  the  flow  of 
blood,  and  comparing  his  sensation  at  such  periods,  with  those 
he  had  previously  experienced ;  and  if  upon  trial  he  can  fill  his 
lungs  without  pain  or  any  considerable  inconvenience,  we  stop 
the  flow  of  blood,  though  the  pulse  may  still  be  vigorous;  while 
on  the  other  hand,  if  little  or  no  advantage  has  been  gained,  we 
continue  to  abstract  until  this  end  be  obtained;  or  until  the  pulse 
flutter  under  the  finger,  or  syncope  supervene. 

1583.  It  must  therefore  be  evident,  that  no  quantity  express- 
ed by  weight  or  measure  can  be  satisfactory ;  since,  it  cannot  be 
determined,  a  priori,  what  the  quantity  shall  be.     If  we  are  re- 
gulated by  the  first  mentioned  condition,  namely,  relief,  though 
the  pulse  be  still  active,  we  are  very  certain  that  similar  benefit 
will  be  effected  by  a  repetition  of  the  bleeding,  should  a  new  ne- 
cessity be  created ;  since,  it  shows  so  vigorous  a  condition  of  the 
heart,  as  to  give  assurance,  that  the  system  can  still  bear  with 
advantage  a  further  loss  of  blood.     When  bleeding  is  repeated, 
we  are  regulated  by  the  same  rule,  and  so  on,  until  the  disease 
is  subdued;  or  until  we  are  assured,  that  we  cannot  profitably 
abstract  more  blood  by  the  lancet.  But  even  in  this  case,  we  do 
not  abandon  the  depletion  from  the  circulating  system,  for  we 
now  have  recourse,  either  to  cupping  or  leeching,  for  by  either 


PNEUMONIA,   OR   PERIPNEUMONIA.  439 

of  these  means,   we  can  unload  the  blood-vessels  oftentimes 
with  as  much  certainty  as  success. 

1584.  Either  of  the  means  just  named  may  be  had  recoure  to; 
and  the  quantity  drawn  must  be  regulated  by  the  existing  exi- 
gency. In  all  pneumonic  inflammations,  whether  of  the  bronchia, 
the  pleura,  or  the  substance  of  the  lungs,  we  have  for  some  years 
past  persuaded  ourselves  that  the  part  selected  for  the  operation 
should  be  high  between  the  shoulders,  unless  the  seat  of  the  affec- 
tion is  distinctly  indicated  by  local  pain;  in  this  case,  cupping 
immediately  over  the  part  seems  to  be  more  advantageous  than 
between  the  shoulders ;  but  this  does  not  appear  to  be  the  case 
when  leeching  is  resorted  to,  as  this  does  not  afford  equal  relief 
when  applied  over  the  pained  part. 

1585.  In  the  second  case,  or  where  we  persevere  in  abstract- 
ing blood  because  relief  is  not  afforded,  and  where  we  are  obliged 
to  stop  because  the  pulse  is  much  reduced,  or  syncope  has  super- 
vened, we  are  almost  constantly  under  the  necessity  of  repeating 
the  operation  sooner  than  in  the  first  case,  because  a  reaction  of 
considerable  force  is  sure  to  follow  pretty  quickly,  if  the  bleed- 
ing has  been  performed  in  the  early  part  of  the  disease,  and  in  a 
generally  hale  constitution.     In  this  case,  indeed,  we  may  ven- 
ture to  say  in  every  case  where  this  odcurs,  the  drawing  of  blood 
should  be  immediately  resorted  to ;  and  we  must  not  lose  valua- 
ble time,  by  waiting  a  certain  given  number  of  hours,  as  is  some- 
times directed.     For  the  only  proper  time  for  drawing  blood,  is 
when  there  is  a  mischievous  degree  of  excitement ;  and  if  this 
occur  when  two,  or  not  until  twelve  hours  have  elapsed,  it  is  ab- 
solutely necessary  to  draw  blood  at  the  instant  of  its  recurrence; 
and  in  this  instance,  the  one  period  is  just  as  proper  as  the  other. 
We  therefore  never  gain  any  thing  by  permitting  hours  to  go- 
vern us ;  the  existing  state  of  the  system  is  the  only  valuable,  or 
even  safe  rule.     The  pulse  must  here,  as  before,  be  our  guide, 
together  with  the  state  of  the  affection  of  the  chest,  as  regards 
pain,  cough,  breathing,  &c. 

1586.  In  referring  so  frequently  to  the  state  of  the  pulse,  we 
wish  to  be  understood  to  refer,  to  its  tension,  or  what  is  usually 
called  its  hardness,  rather  than  its  activity  or  volume.     For  a 
hard  pulse  may  continue  even  longer  than  we  can  profit  by  draw- 
ing blood ;  for,  however  certainly  it  may  declare  inflammation, 
we  nevertheless  do  little  towards  the  reduction  of  the  inflamma- 
tion, if  we  cannot  reduce  its  hardness  by  blood-letting;  yet  it  is 
the  only  means,  either  generally,  or  locally  employed,  by  which 
we  can  obtain  the  end  in  view.     Yet  so  indomitable  is  this  con- 
dition of  the  pulse  at  times,  that  though  bleeding  is  the  only  re- 
source we  have  left,  it  is  yery  far  from  being  always  successful. 
Therefore  we  must  constantly  look  upon  a  persevering  hard  pulse 


460  PNEUMONIA,    OR    PERIPNEUMONIA. 

without  an  abatement  of  the  threatening  symploms,  always  to  be 
a  bad  sign ;  so  true  is  this,  that  we  have,  in  more  instances  than 
one,  known  it  to  preserve  this  condition  while  life  was  at  its 
lowest  ebb. 

1587.  We  have  already  stated,  that  directing  the  quantity  of 
blood  to  be  drawn,  by  fixing  the  number  of  ounces,  was  not  only 
vague,  but  unsafe;  but  an  equal  risk  is  not  run  when  the  loss 
shall  be  regulated  by  the  impression  it  makes  upon  the  pulse, 
and  the  force  of  the  disease.    For,  if  these  be  the  guides,  allow- 
ance is  constantly  and  certainly  made  for  all  the  contingencies 
that  may  present  themselves  in  consequence  of  age,  sex,  consti- 
tution, force,  and  period  of  the  disease,  &c.     A  certain  amount 
of  blood  must  be  lost  under  either  of  these  circumstances,  in 
every  case  of  pneumony  that  remains  susceptible  of  cure;  but 
this  amount  can  never  be  determined  with  any  kind  of  certainty 
by  any  combination  of  round  numbers ;  therefore,  such  direc- 
tions should  be  discarded  from  the  history  of  the  medical  treat- 
ment of  any  disease.     The  other  method  can  hardly  deceive  us, 
if  we  resolve,  as  we  should  do  in  every  case  of  great  exigency, 
to  watch  the  effect  of  the  operation  upon  the  pulse,  and  ths  force 
of  the  disease ;  whenever,  therefore,  any  nicety  is  required  in 
the  quantity  of  blood  to  be  drawn,  the  physician  should  perform 
the  operation  himself,  or  witness  it  when  performed  by  another. 
We  are  certain  that  we  have  derived  the  most  unequivocal,  and 
prompt  advantage  from  this  plan — sometimes,  causing  much 
more  to  be  drawn  than  we  at  first  had  supposed  would  be  neces- 
sary; and  at  other,  arresting  the  operation,  before  the  prescribed 
quantity  had  been  taken.     Now,  had  either  of  these  cases  been 
submitted  to  a  fixed  quantity,  mischief  must  necessarily  have 
followed. 

1588.  To  the  inexperienced  practitioner  certainly,  and  occa- 
sionally perhaps  to  the  experienced  physician,  the  method  just 
spoken  of  holds  out  decided  advantages  in  those  oftentimes  equi- 
vocal states  of  the  pulse,  called  the  depressed,  or  the  oppressed 
pulse,  (see  note  to  par.  352,)  and  the  pulse  of  real  debility.    So 
much  difficulty  is  generally  experienced  in  distinguishing  these 
opposite  states,  and  this  with  men  of  large  experience,  that  it  be- 
comes a  matter  of  equal  chance,  whether  bleeding  or  stimulation 
would  be  the  proper  remedy.     But  the  mischief  which  might 
arise  from  a  mistake  of  the  indication  is  prevented  with  cer- 
tainty, if  the  physician  remain  with  his  patient  while  the  bleed- 
ing is  performed,  as  the  pulse  will  either  rise  or  fall,  in  an  in- 
stant.  (See  par.  1563.) 

1589.  As  a  general  rule  in  pneumonia,  more  is  to  be  feared, 
that  an  inadequate  quantity  of  blood  w,ill  be  drawn,  than  that  the 
proper  quantity  will  be  exceeded.  This  apprehension  arises  from 


PNEUMONIA,   OR    PEBIPNEUMONIA.  461 

almost  all  practitioners  being  sorely  afraid  of  "  debility" — this 
fear  paralyzes  like  an  incubus ;  nor  can  they  shake  off  this  dread, 
until  they  have  passed  through  a  severe  ordeal  of  experimental 
uncertainty,  and  find  at  last,  that  debility  in  inself,  is  not  dis- 
ease. 

1590.  Pneumonia  very  often  runs  its  course  with  so  much 
rapidity,  that  it  cannot  be  arrested,  but  by  the  most  decisive 
measures,  and  these  especially  employed  in  its  commencement. 
Of  this  all  practitioners  seem  to  be  aware;  yet,  they  do  not  all 
agree  in  the  extent,  to  which  this  only  remedy,  should  be  car- 
ried; this  timidity  is  both  unnecessary,  and  ill-timed  ;  unneces- 
sary, because  there  is  nothing  to  be  apprehended  from  an  exten- 
sive blood-letting,  if  it  have  been  properly  proportioned  to  the 
force  of  the  disease ;  and  this  can  always  be  ascertained,  if  its 
abstraction  be  regulated  by  its  effects,  and  not  by  an  arbitrary 
number  of  ounces.     The  dread  that  a  large  and  proper  bleeding 
is  excessive,  and  will  reduce  the  patient  to  an  irrecoverable  state 
of  debility,  induces  measures  which  do  not  even  mitigate  the  se- 
verity of  the  symptoms,  much  less  arrest  the  march  of  disor- 
ganizing inflammation. 

1591.  It  is  ill-timed;  because,  while  half-way  measures  are 
performing,  the  disease  is  hastening  on,  with  such  wide  and  ra- 
pid strides,  that  it  cannot  be  overtaken,  should  the  practitioner 
change  his  mind,  and  determine  upon  the  pursuit.     We  would 
here  say  with  Dr.  Gregory,  as  quoted  by  Dr.  Robertson,  (Edin. 
Journ.  Vol.  X.  p.  192,)  "the  danger  of  a  large  bleeding  is  less 
than  the  danger  of  the  disease;"  intimating,  that  its  force  cannot 
be  diminished,  nor  its  fatal  progress  arrested,  but  by  decisive 
measures. 

1592.  Laennec  observes,  "that  many  physicians  of  that  coun- 
try, (England,)  in  the  commencement  of  pneumonia,  direct  the 
detraction  of  twenty-four,  thirty,  or  thirty-six  ounces  of  blood. 
The  practice  is.  not  to  be  found  fault  with,  since  it  is  certain  that 
a  copious  bleeding  in  the  beginning  of  the  disease,  reduces  the 
inflammatory  orgasm  much  more  speedily,  than  repeated  small 
venesections  will  do  at  a  later  period,  and  moreover  leaves  less 
chance  of  a  renewal  of  the  inflammation."  p.  239.     These  re- 
marks of  this  very  accurate  observer,  distinctly  show,  that  it  was 
his  opinion,  that  a  strong  impression  must  be  made  upon  this  dis- 
ease at  its  very  commencement,  and  that  this  object  could  only 
be  fulfilled  by  the  abstraction  of  a  considerable  quantity  of  blood 
at  one  time.  In  this  it  will  be  perceived,  he  only  coincides  with 
the  best  writers  on  this  subject  of  both  ancient  and  modern  times, 
and  in  which  we  most  heartily  agree;  with  the  exception,  how- 
ever, that  we  have  already  made,  that  the  quantity  about  to  be 


462  PNEUMONIA,   OR    PERIPNEUMONIA. 

drawn,  must  be  determined  by  the  effects,  and  not  by  the  num- 
ber of  ounces;  for  this  never  can  be  made  a  certain,  nay,  perhaps 
not  even  a  safe  guide.  For  the  same  constitutional  effects  will 
be  produced  by  the  loss  of  very  different  quantities  of  blood ; 
thus,  we  have  seen  fifteen  or  twenty  ounces  achieve,  in  one  con- 
stitution, what  would  require  in  another  forty  or  even  fifty. 
Therefore  we  must  protest  against  the  ounce  rule  of  drawing 
blood,  though  such  high  authority  as  Laennec,  declares  "it  is 
not  to  be  found  fault  with;"  for  if  this  direction  were  literally 
obeyed,  we  should  sometimes  stop  this  side  of  the  proper  effect, 
and  at  others  it  would  go  beyond  its  usefulness;  either  of  which 
would  create  its  dangers. 

1593.  Laennec  further  observes,  that  "the  ancients  consider- 
ed bleeding  as  a  questionable  remedy  after  the  first  days  of  the 
disease,  fearing  thereby  to  check  the  expectoration;  and  the  best 
practitioners  of  the  two  last  centuries  forbad  this  operation  after 
the  fifth  day,  if  the  discharge  was  mucous  and  abundant."  Here 
is  another  popular  rule ;  a  rule  founded  on  the  number  of  days 
that  the  disease  has  run;  which  is  as  vague,  to  say  the  best  of  it, 
as  the  one  we  have  just  been  considering;  for  if  it  be  a  fact  that 
bleeding  will  arrest  expectoration  at  any  one  period  of  the  dis- 
ease, no  matter  which,  it  can  only  do  so,  from  some  peculiar  con- 
dition of  the  system  at  large,  or  of  the  thoracic  viscera  in  parti- 
cular.  Now  this  condition,  agreeably  to  the  rule  thus  laid  down, 
takes  place  as  a  law  of  the  system,  but  after  the  expiration  of  the 
fifth  day;  yet  the  condition  required  to  render  blood-letting  in- 
jurious, if  it  ever  take  place,  must  necessarily  be  contingent  upon 
the  force  of  the  disease,  the  age,  constitution,  and  peculiarities 
of  the  patient,  epidemic  influence,  location,  and  modes  of  treat- 
ment; consequently,  cannot  be  dependent  upon  the  number  of 
days,  that  the  disease  has  existed.     Therefore,  if  it  be  true,  that 
bleeding  will  stop  the  spitting  in  pneumonia,  in  any  case,  the  pe- 
culiar condition  of  the  system  in  which  this  takes  place,  should 
have  been  carefully  pointed  out,  that  the  error  may  not  be  com- 
mitted— but  this  we  believe  has  never  been  done;  nor  have  we 
ever  witnessed  the  effect  alleged  to  be  produced  by  bleeding,  at 
any  period  in  pneumonia. 

1594.  If  this  stoppage  of  expectoration  take  place  soon  after 
bleeding,  there  is  more  reason  to  believe  it  to  be  coincidence, 
than  cause,  and  effect.   For  it  is  every  way  certain,  that  mucous 
expectoration  only  takes  place  from  either  severe  irritation,  or 
a  moderate  degree  of  inflammation,  and  if  the  former  be  exces- 
sive, the  latter  will  be  produced  ;  and  if  this  be  beyond  a  certain 
degree,  the  vessels  become  unable  to  relieve  themselves  by  the 
formation  of  mucus,  and  its  excretion  will  be  stopped.    But  is  it 


PNEUMONIA,   OR    PERIPNEUMONIA.  463 

not  absurd  to  suppose  that  blood-letting  will  increase  the  inflam- 
mation of  the  bronchial  membrane  ?  Yet  this  must  happen  if  ex- 
pectoration be  interrupted. 

1595.  It  is  true,  that  Laennec  seems  to  admit  that  this  appre- 
hension may  be  well  founded  under  certain  circumstances;  for 
he  says,  "  apprehensions  of  this  kind  are  not  perhaps  unreason- 
able, if  the  loss  of  blood  be  carried  to  syncope."     In  this  asser- 
tion, he  evidently  has  chosen  an  extreme  case  to  found  his  assent 
upon;  and  it  savours  strongly  of  an  hypothesis,  to  which  how- 
ever he  is  very  little  given  in  common,  rather  than  the  result  of 
personal  experience.     For  he  adds  immediately  after,  "  but  we 
know  from  experience  that  in  a  lesser  degree,  though  still  pretty 
copious,  blood-letting  may  be  had  recourse  to  with  much  advan- 
tage, in  a  very  advanced  period  of  pneumonia,  even  when  this 
has  reached  the  suppurative  stage,  and  is  attended  with  great  ex- 
pectoration." 

1596.  We  may  therefore  reduce  the  treatment  of  pneumonia, 
as  far  as  regards  the  abstraction  of  blood,  to  the  few  simple  rules 
laid  down  by  Diemerbrock.  He  says,  "  a  vein  of  the  arm  should 
be  opened  immediately,  and  the  blood  be  permitted  to  flow  free- 
ly; should  this  bleeding  fail  to  mitigate  the  disease,  it  should  be 
repeated,  even  a  third  time,  if  necessary;  and  although  this  may 
diminish  the  patient's  strength,  yet  nothing  is  to  be  feared  from 
this;  for  it  is  far  better  the  weakened  sick  should  be  cured,  than 
that  the  strong  die." 

1597.  Laennec  however  declares,  "there  are  some  cases  in 
which  blood-letting  is  clearly  contraindicated,  or  at  least  in  which 
it  can  only  be  used  very  sparingly,  and  once  or  twice  at  most. 
Of  this  kind  is  the  peripneumony  which  attacks  old  people  of  a 
cachectic  habit,  and  that  which  supervenes  to  diseases  which  ex- 
hibit obvious  signs  of  a  sceptic  state  of  the  fluids,  such  as  violent 
continued  fevers,  called  putrid  or  adynamic,  and  scurvy."     Of 
this  kind,  was  said  to  be,  the  peripneumony  that  extended  along 
many  of  our  great  waters  in  this  state  a  few  years  ago.     In  this 
epidemic,  a  practitioner  residing  at  Miller's  town,  Cumberland 
county,  informed  me  that  he  had  seen  much  of  the  disease,  and 
that  in  every  instance  in  which  he  employed  blood-letting,  the 
patient  died.     Of  the  peculiarities  of  this  epidemic  we  can  say 
very  little  from  our  own  experience,  having  seen  but  two  cases 
in  the  neighbourhood  in  which  we  then  resided;  but  both  these 
patients  were  from  the  east  side  of  the  Allegheny  Mountains, 
and  from  a  district  in  which  the  disease  in  question  was  very 
rife.     In  both  instances  we  employed  the  lancet  liberally ;  one 
we  bled  seven  times,  and  the  other  three — both  recovered  ra- 
pidly.    These  cases  were  similar,  as  far  as  could  be  determined 
from  a  history  of  the  symptoms,  to  the  majority  of  cases  that  oc- 


464  PNEUMONIA,    OR    PERIPNEUMONIA. 

curred  along  the  Juniata  river,  and  in  which  venesection  was 
said  to  be  uniformly  injurious. 

1598.  We  do  not  however  wish  to  be  considered  as  deny- 
ing the  modifying  powers  of  epidemic,  or  other  accidental  in- 
fluences— on  the  contrary,  we  sincerely  believe  in  them;  we 
would  only  wish  to  be  considered  as  cautioning  against  a  too 
great  facility  of  credence,  upon  this  head  ;  because  we  know  the 
point  has  been  yielded  in  many  instances,  with  too  much  ease, 
and  much  to  the  injury  of  the  sick.     Laennec  furnishes  us  with 
instances  of  the  controlling  effects  of  epidemic,  and  other  causes, 
which  are  every  way  in  point,  and  to  which  he  himself  was  wit- 
ness.    He  says,  "  In  certain  epidemics,  which  have  happened 
among  persons  previously  subjected  to  the  influence  of  depress- 
ing causes,  bleeding  has  been  found  uniformly  injurious.     I  was 
myself  witness  to  an  instance  of  this  kind  among  the  conscripts 
of  the  French  army  in  the  year  1814.     In  the  pneumonia  then 
prevalent  I  very  seldom  found  bleeding  indicated,  and  the  small 
number  who  were  bled,  bore  the  operation  so  ill  that  I  did  not 
venture  to  repeat  it."  p.  242.     Regard  should  therefore  always 
be  paid  to  the  character  of  the  modifying  causes,  if  our  prescrip- 
tions are  to  be  successful  in  their  proper  proportion. 

2.  General  Evacuants. 

1599.  We  may  divide  these  into  emetics,  cathartics,  and  ex- 
pectorants.    Of  the  first  of  these  little  need  be  said,  as  they  are 
resorted  to  in  general  to  fulfil  but  a  single,  and  perhaps  only  a 
temporary  indication;  and  even  that  is  very  much  confined  to 
the  cases  of  children.     This  case  is  where  the  bronchia  and  tra- 
chea appear  to  be  oppressed  by  accumulated  phlegm,  and  respi- 
ration much  oppressed  in  consequence — here  an  emetic  of  ipeca- 
cuanha or  the  compound  syrup  of  squills,  have  been  found  of  oc- 
casional use. 

1600.  Cathartics  are  much  less  objectionable  than  emetics; 
because  they  are  decidedly  less  injurious  in  their  operation;  they 
however  are  very  far  from  being  constantly  useful,  or  even  al- 
ways safe.     For  the  most  part  it  rnay  be  said,  that  they  weaken 
by  their  effects  upon  the  bowels,  very  much  beyond  their  use- 
fulness as  evacuants,  in  subduing  the  disease.  This  will  not  sur- 
prise us,  when  we  consider  how  little  controul  cathartics  can 
exert  over  the  pulmonic  circulation;  as  the  blood-vessels  of  the 
abdominal  cavity  have  very  little  connexion  with  those  of  the 
lungs,  and  consequently  have  but  little  agency  in  diminishing 
the  quantity  of  blood  within  them.  But  it  must  not  be  forgotten, 
that  it  is  every  way  important  to  keep  the  bowels  freely  open, 
though  we  would  wish  to  avoid  active  purging;  we  would  there- 


PNEUMONIA,   OB    PEHIPNEUMONIA.  465 

fore  have  recourse  to  laxative  medicines  when  necessary  during 
the  whole  course  of  the  disease.  For  this  purpose  castor  oil, 
magnesia,  rhubarb,  small  doses  of  the  neutral  salts,  or  Seidlitz 
powders,  should  be  made  use  of. 

1601.  Should  gastric,  or  intestinal  irritation,  accompany  pneu- 
monia, as  sometimes  happens,  purging  must  not  be  thought  of; 
the  mildest  laxatives,  and  these  only  when  clearly  indicated  by 
a  too  confined  condition  of  the  bowels,  should  be  resorted  to. 

1602.  As  regards  expectorants,  they  can  never  be  usefully 
employed  until  the  inflammatory  action  is  so  far  reduced,  that 
the  vessels  of  themselves  throw  out  a  mucous  fluid  ;  and  when 
this  period  arrives,  they  seem  to  be  unnecessary,  as  this  effect 
will  take  place  for  the  most  part  without  their  aid.     We  have 
ever  found  the  lancet,  and  very  mild  diluents,  to  be  the  best  ex- 
pectorants; though  we  have  certainly  found  advantage,  in  the 
decline  of  the  disease,  from  small,  but  repeated  doses  of  the 
hive  syrup,  or  the  compound  syrup  of  squills.     We  are  of  opi- 
nion, that  this  compound  is  the  best  of  the  expectorants,  as  the 
stimulating  qualities  of  the  squill,  and  the  seneka,  are  controlled 
by  the  tartrite  of  antimony,  which  enters  into  its  composition.* 
Inhaling  the  vapour  from  hot  water,  and  a  free  use  of  thin  flax- 
seed,  or  bran  tea,  barley  water,  the  infusion  of  the  bark  of  the 
slippery-elm,  (Ulmas  fulva,)  or  a  thin  solution  of  gum  Arabic, 
are  among  the  most  efficacious  expectorants.     Expectorants,  pro- 
fessedly so  considered,  should  never  be  administered  before  the 
air-cells  are  so  far  relieved  of  their  inflammatory  action,  that  the 
exhalants  can  really  assume,  or  at  least  in  part,  their  healthy  ac- 
tions; one  of  which  certainly  is,  to  pour  out  mucus;  and  of 
which  they  are  to  be  relieved  by  hawking,  or  coughing;  for  the 
whole  class   of  expectorants   possess  considerable   stimulating 
powers;  especially  the  gums  or  balsams,  the  squills,  &c.     The 
tartrite  of  antimony  and  ipecacuanha  are  the  only  exceptions 
perhaps  to  the  rule ;  and  they  probably  owe  their  expectorant 
virtues  to  a  semi-emetic  action,  or  some  influence  upon  the  mu- 
cous tissue  of  the  stomach ;  and  thus  indirectly  produce  the  end 
in  view ;  for  it  is  much  to  be  doubted,  if  we  have  a  class  of  medi- 
cines that  specifically  act  upon  the  bronchial  surface,  and  induce 
it  to  an  increase  of  secretion,  though  some  of  them,  (as  the  alli- 
aceae,)  are  immediately  applied  to  the  whole  of  it.     The  car- 
bonate of  ammonia  in  pretty  large  doses  has  been  highly  extolled 
as  an  expectorant ;  and  we  once  witnessed  very  decided  benefit 
from  its  employment;  this  was  a  case,  where  the  system  was 
much  prostrated,  the  spitting  much  diminished,  and  the  sputa 
very  tenacious.     In  this  instance  certainly,  and  we  presume  it  to 

*  For  its  composition  see  Chap,  on  Croup. 
59 


466  PNEUMONIA,  OH    PERIPNEUMONIA. 

be  the  case  in  all,  where  ammonia  has  restored  the  expectoration, 
it  acted  but  as  a  general  stimulant,  thereby  imparted  vigour  to  the 
superficial  vessels  of  the  lungs,  and  thus  enabled  them  to  carry 
on  the  process  of  secretion. 

ft 

3.  Blisters. 

1603.  We  have  already  spoken  of  these  remedies,  when  treat- 
ing of  fever;  (p.  83,)  what  we  have  said  there  will  sufficiently 
direct  their  use  in  pneumonia  as  regards  the  state  of  the  pulse  or 
system ;  that  is,  they  are  never  to  be  applied,  so  long  as  the  dis- 
ease will  require  general  bleeding.     The  part  to  which  they  are 
to  be  applied,  is  a  matter  of  some  consequence — if  local  pain  in 
the  chest  exist,  the  blister  should  be  applied  over  the  pained  part; 
if  there  be  none,  as  sometimes  is  the  case,  and  only  a  general 
soreness  of  the  chest,  between  the  shoulders  appears  to  be  the 
place,  that  gives  the  most  certain  relief. 

4.  Alteratives. 

1604.  We  cannot  imagine,  that  the  medicines  which  are  com- 
monly given  as  alteratives,  can  possibly  have  any  beneficial  effect 
in  pneumonia,  unless  it  run  on  to  a  chronic  state. 

5.  Tonics. 

1605.  Of  this  class  of  remedies  in  pneumonia,  we  know  no- 
thing from  our  own  experience,  unless  it  be  their  occasional  em- 
ployment at  the  decline  of  the  disease.     Of  the  epidemics,  which 
would  seem  from  highly  respectable  authority  to  require  this 
plan  of  treatment,  we  know  nothing — under  such  circumstances, 
we,  however,  think  it  proper  to  state  what  others  say  upon  this 
subject;  as  such  epidemics  may  infest  this  country,  as  it  appears 
they  have  done  Europe. 

1606.  For  this  purpose  we  shall  quote  from  Laennec,  as  he  is 
generally  opposed  to  the  use  of  this  class  of  remedies  in  acute 
diseases.     He  says,   "these,   (tonics,)  and  especially  bark,  are 
often  very  useful  in  the  peripneumonies  of  old  people,  and  de- 
bilitated and  cachectic  subjects,  especially  towards  the  termina- 
tion of  the  disease,  when,  after  the  suppurative  stage,  the  fever 
passes  off,  and  resolution  goes  on  very  slowly."     "  We  some- 
times even  meet  with  epidemic  peripneumonies  in  which  blood- 
letting is  constantly  hurtful,  and  bark  beneficial  in  every  stage 
of  the  disease.     This  fact,  which  cannot   be  denied,  was  fre- 
quently witnessed  in  Germany,  towards  the   close  of  the  last 
century;  and  there  is  no  doubt  that  Brown's  theory  was  indebt- 


PNEUMONIA,  OU    PERIPNEUMONIA.  467 

iifa 

cd  to  this  medical  constitution  for  a  portion  of  the  fame  it  ob- 
tained in  that  country.  A  number  of  such  examples  are  recorded 
in  the  old  Journal  de  Medecine;  and  I  have  myself  met  with 
many,  particularly  among  the  troops  in  1814,  (see  par.  1598,) 
already  mentioned.  In  gangrene  of  the  lungs,  cinchona  is  the 
best  remedy.  I  have  used  it  successfully,  even  in  cases  where 
hepatization  around  the  eschar  was  very  extensive;  and  have 
sometimes  combined  wine  and  opium  with  it,  when  the  violence 
of  the  inflammatory  symptoms  had  begun  to  subside.  To  be 
effectual,  it  must  be  given  to  the  extent  of  an  ounce  of  the  pow- 
der, or  an  equivalent  portion  of  the  extract,  daily.  In  several 
eases  I  have  continued  to  give  the  sulphate  of  quinine  for  more 
than  a  month,  to  the  extent  of  eighteen  grains  in  the  twenty- 
four  hours."  p.  246. 

1607.  Of  opium,  which  Laennec  enumerates  among  the  to- 
nics, he  speaks  disparagingly.     He  says,  "  by  itself  it  has  never, 
as  far  as  I  know,  been  recommended  as  a  remedy  in  pneumonia. 
We  even  know  that  it  is  capable,  in  large  doses,  of  producing 
the  disease — instances  of  which  I  have  myself  seen  subsequent 
to  cases  of  poisoning.    It  has,  however,  been  sometimes  employ- 
ed with  success  in  the  same  circumstances  as  the  bark.     With 
these  exceptions  it  should  be  only  used,  and  then  cautiously,  to 
quiet  nervous  irritation,  to  procure  sleep,  or  to  check  an  exces- 
sive diarrhoea."  p.  247.     In  this  statement  there  is  a  little  pre* 
judice  against  this  article,  if  we  can  judge  from  our  own  expe- 
rience; for  this  has  taught  us  to  believe,  that  opium  is  occasion- 
ally highly  useful  in  pneumonia,  after  a  sufficient  abatement  of 
the   inflammatory  action,  and  especially  where  there  is  great 
watchfulness,  and  an  harassing  cough.     Hamilton  and  Armstrong 
are  decided  advocates  for  its  employment  after  liberal  blood-let- 
ling.     The  former  exhibited  it  with  calomel — from  one,  to  five 
grains  of  the  latter,  with  from  a  quarter,  to  a  grain,  of  the  for- 
mer, every  six,  eight,  or  twelve  hours,  according  to  the  severity 
ef  the  disease,  "after  bleeding  and  opening  of  the  bowels."    The 
latter,  orders  at  least  three  grains,  after  bleeding  to  syncope  or 
approaching  syncope.     He  uses  much  larger  doses  of  calomel 
than  is  recommended  by  Dr.  Hamilton.     Dr.  Forbes  also  adds 
his  testimony  in  favour  of  this  plan. 

6.    Tartar  Emetic  in  Large  Doses  in  Pneumonia. 

1608.  From  the  frequency,  severity,  and  danger  of  inflamma- 
tions of  the  respiratory  organs,  much  interest  is  necessarily  ex- 
cited; and  consequently  a  strong  desire  must  be  felt  to  discover 
some  remedy  that  shall  abate  the  one,  and  diminish  the  other. 
We  therefore  feel  it  a  duty  to  lay  before  our  readers  every  thing 


468  PNEUMONIA,   OR    PERIPNEUMONIA. 

which  may  tend  to  satisfy  this  interest ;  especially  when  the  tes- 
timony is  so  much  in  favour  of  the  remedy  now  under  consider- 
ation, and  especially,  when  its  claims  are  so  strongly  supported, 
by  so  accurate  an  observer,  so  cautious  a  practitioner,  and  so  can- 
did and  faithful  a  relator,  as  Laennec,  from  whose  Chapter  on. 
Peripneumony  we  make  the  following  long,  but  highly  interest- 
ing extract.  We  do  this  the  more  willingly,  because,  he  is  not 
the  inventor  of  the  method  of  cure  about  to  be  considered ;  and 
whatever  enthusiasm  he  may  appear  to  indulge  in,  it  is  certain, 
it  does  not  proceed  from  the  pride  of  a  discoverer,  but  the  honest 
zeal  of  a  faithful  and  watchful  investigator  of  disease. 

1609.  He  says,  "the  preparations  of  antimony  have  been  em- 
ployed in   large   doses,  either    empirically,  or   on    theoretical 
grounds,  as  a  means  of  cure  in  different  inflammatory  diseases. 
During  the  seventeenth  century,  more  especially,  to  judge  from 
the  remaining  memorials  of  the  controversies  of  those  days, 
some  brilliant  cures  and  many  unfortunate  events  were  the  conse- 
quence of  this  practice.     These  latter  results  may  perhaps  be  at- 
tributed partly  to  the  preparations  being  too  active,  and  partly  to 
ignorance  of  the  proper  method  of  using  them.     Be  this  as  it 
may,  we  meet  with  traces  of  this  practice,  from  time  to  time,  in 
the  writings  of  the  physicians  of  the  last  century.    I  do  not  here 
allude  to  the  exhibition  of  the  medicine  in  small  doses  as  an 
emetic,  nor  to  the  method  of  Riviere,  who  vomited  his  pneumo- 
nic patients  with  it  daily,  or  every  second  day;  but  may  remark, 
in  passing,  that  this  practice  has  always  had  partizans  among  prac- 
titioners.    It  was  constantly  followed  to  my  own  knowledge,  by 
Dr.  Dumangin,  physician  to  La  Chariti,  in  peripneumony.  This 
gentleman  scarcely  ever  combined  blood-letting  with  it,  and  yet 
his  practice  was  quite  as  successful  as  that  of  Corvisart,  who  bled 
much  in  this  disease.    But  administered  in  this  way,  the  remedy 
is  an  evacuant,  and  its  good  effects  may  consequently  be  attributed 
to  the  derivation  operated  by  it,  on  the  intestinal  canal." 

1610.  "  The  employment  of  Kermes'  mineral  as  an  expecto- 
rant, may  be  considered  as  a  relic  of  its  ancient  use  as  an  alterant. 
In  the  old  Formulaire  des  Hbpitaux  de  Paris,   printed  in 
1764,  we  find  the  remains  of  a  still  bolder  practice,  in  a  potion 
entitled  inpluritide  tt  in  peripneumonia,  and  which  consists 
of  four  drachms  of  the  white  oxide  of  antimony  in  four  ounces 
of  the  infusion  of  borage.  The  famous  bolus  ad  quartanam,  of 
La  Charite,  is  another  proof  of  the  employment  of  antimony  in 
large  doses,  and  as  an  alterant.     I  have  been  informed  that  the 
practice  of  giving  antimony  to  this  extent  was  longer  pursued  in 
Italy  than  in  the  other  countries  of  Europe.     At  all  events,  it  is 
to  a  modern  Italian  physician,  Rasori,  that  we  are  indebted  for 
the  revival  and  demonstration  of  the  utility  of  this  method,  which 


PNEUMONIA,   OR    PERIPNEUMONIA.  469 

had  fallen  too  much  into  disuse.  I  say  nothing  here  of  this  au- 
thor's theory,  or  rather  of  the  modification  of  the  theory  of 
Brown.  The  doctrine  of  stimulus  and  contra-stimulus  has 
hitherto  found  partizans  only  in  Italy,  and  will  perhaps  never 
reach  beyond  the  Alps ;  but  practical  facts  of  such  importance  as 
those  in  question,  ought  to  find  all  medical  men,  whatever  be 
their  theoretical  opinions,  disposed  to  put  them  to  the  test  of  ex- 
periment. I  am  unacquainted  with  the  details  of  Rasori's  prac- 
tice, further  than  as  these  are  stated  in  his  History  of  the  Pete- 
chial  Epidemic  of  Genoa.  The  first  idea  I  had  of  his  method 
was  derived  from  some  medical  men  who  had  been  in  Italy.  I 
began  to  make  trial  of  it  in  1817,  having  learned  at  this  time 
that  my  colleague,  M.  Kapeler,  had  tried  it  with  some  benefit, 
and  without  any  inconvenience,  in  cases  of  apoplexy.  For  a 
long  time  I  restricted  with  him,  my  trials  to  this  disease ;  but 
having  occasion  to  attend  two  cases  of  peripneumony,  in  which 
venesection  was  not  practicable,  I  resolved  to  make  use  of  the 
tartar  emetic  in  large  doses:  and  the  recovery  of  both  patients, 
equally  rapid  as  unexpected,  encouraged  me  to  repeat  its  em- 
ployment in  many  other  cases." 

1611.  "I  shall  here  detail  the  manner  in  which  I  administer 
this  remedy,  and  which  differs,  I  believe,  in  some  respects  from 
that  of  Rasori.  As  soon  as  I  recognise  the  existence  of  the  pneu- 
monia, if  the  patient  is  in  a  state  to  bear  venesection,  I  direct 
from  eight  to  sixteen  ounces  of  blood  to  be  taken  from  the  arm. 
I  very  rarely  repeat  the  bleeding,  except  in  patients  affected 
with  disease  of  the  heart,  or  threatened  with  apoplexy,  or  some 
other  internal  congestion.  More  than  once  I  have  effected  very 
rapid  cures  of  intense  peripneumonies  without  bleeding  at  all ; 
but,  in  common,  I  do  not  think  it  right  to  deprive  myself  of  a 
means  so  powerful  as  venesection,  except  in  cachectic  or  debili- 
tated subjects.  In  this  respect,  M.  Rasori  does  the  same.  I 
regard  blood-letting  as  a  means  of  allaying  for  a  time  the  vio- 
lence of  the  inflammatory  action,  and  giving  time  for  the  emetic 
tartar  to  act.  Immediately  after  bleeding  I  give  one  grain  of  the 
tartar  emetic,  dissolved  in  two  ounces  and  a  half  of  cold  weak  in- 
fusion of  orange  leaf,  sweetened  with  half  an  ounce  of  syrup  of 
marsh  mallows  or  orange  flowers;  and  this  I  repeat  every  second 
hour  for  six  times;  after  which  I  leave  the  patient  quiet  for  seven 
or  eight  hours,  if  the  symptoms  are  not  urgent,  or  if  he  experi- 
ences any  inclination  to  sleep.  But  if  the  pneumonja;has  already 
made  progress,  or  if  the  oppression  is  great,  or  the  head  affected, 
or  if  both  lungs,  or  one  whole  lung  is  attacked,  I  continue  the  me- 
dicine uninterruptedly,  in  the  same  dose  and  after  the  same  in- 
tervals, until  there  is  an  amendment,  not  only  in  the  symp- 
toms, but  indicated  also  in  the  stethoscopic  signs.  Sometimes 


470  PNEUMONIA,    OR    PERIPNEUMONIA. 

even,  particularly  when  most  of  the  above-mentioned  unfavour- 
able symptoms  are  combined,  I  increase  the  close  of  the  tartar 
emetic  to  a  grain  and  a  half,  two  grains,  or  even  two  grains  and 
a  half,  without  increasing  the  quantity  of  the  vehicle.     Many 
patients  bear  the  medicine  without    being    either  vomited    or 
purged.   Others,  and  indeed  the  greater  number,  vomit  twice  or 
thrice  and  have  five  or  six  stools  the  first  day;  on  the  following 
days  they  have  only  slight  evacuations,  and  often  indeed  have 
none  at  all.     When  once  tolerance  of  the  medicine,  (to  use  the 
expression  of  Rasori,)  is  established,  it  even  very  frequently  hap- 
pens that  the  patients  are  so  much  constipated  as  to  require  clys- 
ters to  open  the  body.     When  the  evacuations  are  continued  to 
the  second  day,  or  when  there  is  reason  to  fear  on  the  first  that 
the  medicine  will  be  borne  with  difficulty,  I  add  to  the  six  doses 
to  be  taken  in  twenty-four  hours,  one  or  two  ounces  of  the  syrup 
of  poppies.     This  combination  is  in  opposition  to  the  theoretical 
notions  of  Rasori  and  Tommasini,  but  has  been  proved  to  me  by 
experience  to  be  very  useful.     In  general  the  effect  of  tartar 
emetic  is  never  more  rapid  or  more  efficient  than  when  it  gives 
rise  to  no  evacuation;  sometimes, however,  its  salutary  operation, 
is  accompanied  by  a  general  perspiration.     Although  copious 
purging  and  frequent  vomiting  are  by  no  means  desirable,  on  ac- 
count of  the  debility  and  hurtful  irritation  of  the  intestinal  canal 
which  they  may  occasion,  I  have  obtained  remarkable  cures  in 
cases  in  which  such  evacuations  had  been  very  copious.     I  have 
met  with  very  few  cases  of  pneumonia  where  the  patient  could 
not  bear  the  emetic  tartar;  and  the  few  I  have  met  with  occurred 
in  my  earliest  trials ;  insomuch  that  this  result  now  appears  to 
me  to  be  attributable  rather  to  the  inexperience  and  want  of  con- 
fidence of  the  physician,  than  to  the  practice.     I  now  frequently 
find  that  a  patient  who  bears  only  moderately  six  grains  with  the 
syrup  of  poppies,  will  bear  nine  perfectly  well  the  following 
day.     At  the  end  of  twenty-four  or  forty-eight  hours  at  most, 
frequently  after  two  or  three  hours,  we  perceive  a  marked  im- 
provement in  all  the  symptoms.     And  sometimes  even,  we  find 
patients,  who  seemed  doomed  to  certain  death,  out  of  all  danger 
after  the  lapse  of  a  few  hours  only,  without  having  ever  experi- 
enced any  crisis,  any  evacuation,  or  indeed  any  other  obvious 
change;  but  the  rapid  and  progressive  amelioration  of  all  the 
symptoms.     In  such  cases  the  stethoscope  at  once  accounts  for 
the  sudden  improvement,  by  exhibiting  to  us  all  the  signs  of  the 
resolution  of  the  inflammation.     These  striking  results  may  be 
obtained  at  any  stage  of  the  disease,  even  after  a  great  portion  of 
the  lung  has  undergone  the  purulent  infiltration.    As  soon  as  we 
have  obtained  some  amelioration,  although  but  slight,  we  may 
be  assured  that  the  continuation  of  the  remedy  will  effect  com- 


PNEUMONIA,    OR   PERIFNEUMONIA.  471 

plete  resolution  of  the  disease,  without  any  fresh  relapse;  and  it 
is  in  regard  to  this  point  more  particularly,  that  the  greatest  prac- 
tical difference  between  the  emetic  tartar  and  blood-letting  con- 
sists. By  the  latter  measure,  we  almost  always  obtained  a  di- 
minution of  the  fever,  of  the  oppression  and  the  bloody  expecto- 
ration, so  as  to  lead  both  the  patient  and  the  attendants  to  believe 
that  recovery  is  about  to  take  place:  after  a  few  hours,  however, 
the  unfavourable  symptoms  return  with  fresh  vigour;  and  the 
same  scene  is  renewed  often,  five  or  six  times,  after  as  many  suc- 
cessive venesections.  On  the  other  hand,  I  can  state  that  I  have 
never  witnessed  these  renewed  attacks  under  the  use  of  the  tar- 
tar emetic.  In  these  cases  we  observe  only  in  the  progress 
towards  convalescence,  occasional  stoppages.  And  this  is  more 
particularly  the  case  in  respect  of  the  stethoscopic  signs ;  as  we 
find  that,  between  the  period  when  the  patient  experiences  a  re- 
turn of  his  appetite  and  strength,  and  fancies  himself  quite  cured, 
and  the  period  at  which  the  stethoscope  ceases  to  give  any  indi- 
cation of  pulmonary  engorgement — more  time  frequently  elapses 
than  between  the  invasion  of  the  disease  and  the  beginning  of 
the  convalescence.  It  is  necessary  to  observe,  however,  that 
this  remark  is  still  more  frequently  applicable  to  the  disease 
when  treated  by  blood-letting;  and  moreover,  that  the  patients 
subjected  to  the  antimonial  method  never  experience  the  long 
and  excessive  debility  which  too  often  accompanies  the  con- 
valescence of  those  who  had  been  treated  by  repeated  venesec- 
tions." 

1612.  "  The  best  way  of  appreciating  any  particular  mode  of 
treatment  is  by  its  results.  I  am  sorry  to  say  I  began  only  last 
year  to  keep  an  exact  account  of  mine  by  the  tartar  emetic ;  but  I 
can  affirm  that  I  have  no  recollection  of  death  from  acute  pneumo- 
nia in  any  case  where  this  medicine  had  been  taken  long  enough 
for  its  effects  to  be  experienced.  I  have  only  witnessed  a  few 
fatal  terminations  where  the  case  was  a  slight  peripneumony  com- 
plicated with  severe  pleurisy.  I  have  also  lost  some  patients, 
who,  besides  the  pneumonia,  were  affected  with  cancer,  phthisis, 
disease  of  the  heart,  &c.  and  these  are  the  cases  where  I  had  an 
opportunity  of  observing  the  different  degrees  of  resolution  in  this 
disease.  Finally,  I  have  lost  some  who  were  brought  to  the  hos- 
pital moribund,  and  who  sunk  before  they  had  taken  more  than 
two  or  three  grains  of  the  remedy.  In  the  year  1824,  at  the 
Clinic  of  the  Faculty  of  Medicine,  I  treated  by  the  tartar  emetic 
twenty-eight  cases  of  pneumonia,  either  simple,  or  complicated 
with  slight  pleuritic  effusions.  Most  of  these  cases  were  very 
severe,  yet  they  were  all  cured,  with  the  single  exception  of  a 
cachectic  old  man,  who  took  but  little  of  the  medicine,  because 
he  bore  it  badly.  During  the  present  year,  (1825,)  I  have  treat- 


472  PNEUMONIA,   OR    PERIPNEUMONIA. 

ed  thirty-four  cases  in  the  same  manner.  Of  these,  five  died;  but 
of  this  number  two  women,  one  aged  fifty-nine  and  the  other 
sixty-nine,  were  brought  to  the  hospital  moribund,  and  sunk  be- 
fore they  had  taken  more  than  two  or  three  doses  of  the  tartar 
emetic;  a  third  died  of  disease  of  the  heart,  when  convalescent 
from  pneumonia;  and  a  fourth  fell  a  victim  to  chronic  pleurisy, 
also  in  the  period  of  resolution  of  sub-acute  peripneumony.  These 
two  last  cases  will  be  detailed  hereafter ;  the  one  at  the  end  of 
the  present  chapter,  the  other  in  the  section  of  pleuro-pneurnonia. 
The  fifth  case  was  that  of  a  man,  seventy-two  years  of  age,  who 
died  of  cerebral  congestion,  on  the  tenth  clay  of  the  disease.  Of 
these  five  cases  then,  the  two  first  cannot  be  adduced  in  either 
way  as  instances  of  the  effect  of  this  remedy;  and  the  two  next 
are  proofs  of  its  efficacy  in  pneumonia,  rather  than  the  contrary. 
The  result,  therefore,  of  the  whole  is.  that  of  fifty-seven  cases  of 
pneumonia  treated  by  the  tartar  emetic,  only  two  individuals, 
both  upwards  of  seventy,  died  of  this  disease  joined  with  cere- 
bral congestion — that  is,  a  little  less  than  one  in  twenty-eight. 
In  private  practice,  during  the  last  three  or  four  years,  I  have 
not  been  called,  in  consultation,  to  cases  of  acute  pneumonia,  or 
to  cases  uncomplicated  with  violent  pleurisy,  except  such  as  ap- 
peared already  threatening  a  fatal  termination ;  and  yet  I  do  not 
remember  a  single  case  which  proved  fatal  under  the  use  of  tar- 
tar emetic ;  except  that  of  a  plethoric  subject,  aged  seventy-two, 
whom  I  attended  along  with  Dr.  Juglar.  This  patient  laboured 
under  a  relapse  of  pneumonia  after  a  delusive  convalescence,  the 
third  attack  of  the  kind  he  had  had  during  the  preceding  fifteen 
months.  The  fever  was  intense,  with  sub-delirium  and  other 
signs  of  cerebral  congestion.  He  took  the  emetic  tartar  to  the 
amount  of  six  grains  daily  for  two  days;  tolerance  was  establish- 
ed on  the  second  day;  the  pneumonic  symptoms  decreased;  the 
expectoration  became  again  mucous  ;  but  he  sunk  on  the  third 
day  from  an  increase  of  cerebral  congestion.  To  this  case  I  can 
oppose  two  others  where  the  probabilities  of  success  were  less, 
and  where,  nevertheless,  a  rapid  recovery  took  place." 

1613.  "A  man  aged  forty-five,  weakened  by  various  excesses, 
was  seized  with  pneumonia,  in  1823.  I  saw  him  on  the  fourth 
day  in  a  state  almost  hopeless.  The  right  lung  was  affected 
throughout,  notwithstanding  venesection  had  been  repeatedly 
used.  There  was  extreme  oppression  of  the  chest;  and  during 
the  last  twelve  hours,  jaundice,  with  pain  in  the  region  of  the 
liver,  had  come  on,  indicating  the  supervention  of  hepatitis.  I 
recommended  the  tartar  emetic,  which  the  attendant,  Dr.  Michel, 
the  more  readily  agreed  to,  from  having  seen  it  used  by  Rasori 
at  Milan.  We  prescribed  twenty  grains,  to  be  taken  during  the 
twenty-four  hours,  in  two  grain  doses;  but  by  mistake  forty 


PNEUMONIA,   OR   PERIPNEUMONIA.  473 

grains  were  given,  within  the  same  period.  This  treatment  oc- 
casioned but  little  evacuation,  and  on  the  following  day,  we  found 
the  jaundice,  the  pain,  and  the  oppression  gone,  the  stethoscopic 
sign  perceptibly  improved,  the  fever  less,  and  the  patient,  in 
short,  out  of  danger.  Convalescence  proceeded  without  any  re- 
lapse. " 

1614.  "In  June,  1825,  I  was  called  to  M.  de  C.  aged  sixty- 
five,  by  MM.  Laudre,  Beauvais,  and  Jadiloux.    I  found  the  pa- 
tient in  the  eleventh  day  of  pneumonia.   He  had  been  repeatedly 
bled  with  marked  relief,  but  this  was  always  speedily  followed 
by  a  renewal  of  the  violence  of  the  disease.  Since  the  preceding 
day  he  had  been  insensible,  and  he  now  lay  with  the  tracheal 
rattle  of  the  dying  and  covered  with  a  sweat,  which  felt  cold  on 
the  extremities.     Two  days  before,  the  debility  not  justifying 
the  loss  of  more  blood,  tartar  emetic  had  been  tried;  but  the  first 
doses  having  increased  a  diarrhoea  which  the  patient  laboured 
under,  and  the  evacuations  having  occasioned  syncope,  the  me- 
dicine was  suspended  after  two  or  three  grains,  at  most,  had 
been  given.  On  examination  both  lungs  were  found  to  be  affect- 
ed ;  the  right  over  great  extent,  and  in  an  advanced  state  of  he- 
patization;  the  left  at  the  roots  and  base,  in  the  state  of  engorge- 
ment and  incipient  hepatization.     I  recommended  the  aromatic 
antimonial  infusion,  in  doses  of  a  grain  and  a  half  of  the  tartar 
emetic,  with  the  syrup  of  poppy.  The  patient  bore  the  medicine 
well,  and  took  eighteen  grains  during  the  first  twenty-four  hours. 
It  did  not  occasion  more  purging  than  had  previously  existed. 
During  the  administration  the  patient  recovered  his  conscious- 
ness; the  rattle,  sweat,  and  oppression  disappeared;  and  when  we 
saw  him  on  the  following  day,  we  found  him  decidedly  conva- 
lescent, the  stethoscopic  signs  indicating  resolution.    The  medi- 
cine was  continued  for  some  days,  and  convalescence  proceeded 
without  any  fresh  relapse.  It  was  questioned  whether  the  sweat 
which  existed  at  the  time  when  the  tartar  emetic  was  administer- 
ed, might  not  have  been  critical  in  this  case.     I  cannot  believe 
that  a  perspiration  of  the  kind  described,  coming  on  with  cere- 
bral congestion,  and  the  tracheal  rattle  of  the  moribund,  ought 
to  be  considered  as  critical,  more  particularly  as  it  as  well  as 
the  other  mortal  symptoms  passed  off  during  the  use  of  the  anti- 
mony." 

1615.  "The  above  results  of  my  practice  are  more  favoura- 
ble than  those  of  Rasori's,  lately  published,  (Revue  Med.  Mai, 
1825.)     This  may  be  owing  to  two  causes — first,  because,  aus- 
cultation enables  us  to  ascertain  the  existence  of  peripneu- 
mony  much  quicker  than  we  could  do  from  the  ordinary  symp- 
toms; and,  secondly,  because,  in  all  probability,  many  cases  of 
simple  pleurisy,  or  of  pleuro-peripneumony  with  predominance 

60 


474  PNEUMONIA,    OR    FEIIIPNEUMONIA. 

of  pleurisy,  are  comprehended  by  Rasori  under  the  name  of  pe- 
ripneumony — it  being  impossible  to  discriminate  these  different 
affections  from  each  other,  without  the  aid  of  auscultation.  I 
have  already  stated  we  must  not  expect  equally  favourable  re- 
sults in  the  treatment  of  pleurisy,  as  in  the  treatment  of  pneu- 
monia, by  the  tartar  emetic." 

1616.  "  My  cousin,  Dr.  A.  Laennec,  physician  of  the  Hotel 
Dieu,  of  Nantes,  has  treated  with  the  tartar  emetic,  during  the 
last  two  years,  forty  cases  of  the  pleuro-pneumonia.  Of  these, 
six  proved  fatal,  three  in  consequence  of  errors  of  regimen  dur- 
ing convalescence.  Subtracting  these,  then,  the  proportion  of 
deaths  will  be  one  to  thirty.*  Dr.  Hellis,  of  Rouen,  has  lately 
presented  to  the  Royal  Academy  of  Medicine,  a  Memoir  on  the 
Treatment  of  Pneumonia,  after  the  Method  of  Riviere  and  Stoll, 
that  is,  by  repeated  emetics. t  Of  forty-seven  cases  treated  by 
him,  he  only  lost  five,  being  a  proportion  somewhat  less  than 
one  in  nine.  This  result,  although  much  less  favourable  than 
that  which  has  followed  the  use  of  the  tartar  emetic  in  large 
doses  in  my  practice,  is  yet  more  so  than  that  obtained  from  the 
employment  of  blood-letting  and  derivatives,  which  I  have  stated 
to  be  one  in  six  or  eight.  Independently  of  being  less  success- 
ful, the  practice  of  Riviere  has  not  even  the  merit  of  being  more 
gentle  than  the  tartar  emetic  in  large  doses,  as  the  repeated  eva- 
cuations occasioned  by  it  produces  great  distress  to  the  patients, 
and  alarm  to  the  attendants,  while  such  effects  take  place  in  the 
other  method,  at  most  only  in  the  two  first  days.  I  continue 
the  use  of  the  medicine  as  long  as  the  tolerance  lasts,  and  while 
there  exists  any  remains  of  the  crepitous  rattle.  This  tolerance 
I  find  every  day  to  continue  indefinitely,  in  patients  in  full  con- 
valescence— a  fact  which  is  not  in  accordance  with  Rasori's 
theory.  If  I  have  been  correctly  informed,  he  considers  the 
tolerance  as  owing  to  the  excess  of  stimulus  existing  in  the  sys- 
tem, and  which  produces  the  disease;  and,  according  to  him,  as 
soon  as  the  excess  of  stimulus  is  destroyed  by  the  contrastimu- 
lant  effect  of  the  tartar  emetic,  the  tolerance  ought  to  cease.  It 
is  certainly  true,  that  after  the  aciate  period  of  the  disease,  the 
tolerance  diminishes,  and  sometimes  entirely  ceases ;  but  it  is 
more  common  to  find  the  patient  become  habituated  to  the  me- 
dicine, insomuch,  that,  during  convalescence,  and  when  he  has 

*  Journ.  de  la  Sect,  de  Med.  de  la  Soc.  Acad.  du  Depart,  de  la  Loire  Infer. 
1825. 

f  "  This  memoir  has  since  been  published  by  the  author  under  the  title 
"  Clinique  Medicate  de  I' Hotel  Dieu  de  Rouen,  Premiere  Anne."  Paris,  1826. 
From  this  work,  and  also  from  another  before  me,  entitled  "  Memoire  sur  lea 
Fluxions  de  Poitrinc,"  par  Louis  Valetin,  M.  D.  Nancy,  1815,  it  would  seem 
that  the  practice  of  giving  emetics  in  pneumonia,  so  much  employed  formerly 
by  StolJ,  and  others,  has  still  many  partizans  in  France." — Note  by  Dr.  Forbes. 


PNEUMONIA,    OR   PERIPNEUMONIA.  475 

begun  to  use  as  much  food  as  in  health,  he  will  take  daily,  with- 
out knowing  it,  six,  nine,  twelve,  and  even  eighteen  grains  of 
the  emetic  tartar.  Putting  aside  entirely  the  question  of  theory, 
I  agree  with  Rasori  in  opinion,  that  the  tartar  emetic  is  in  ge- 
neral better  supported,  and  produces  more  speedy  and  powerful 
effects,  in  proportion  as  the  patient's  constitution,  and  the  symp- 
toms of  the  disease,  bear  the  marks  of  great  plethora,  and  high 
vital  action;  but  I  must,  at  the  same  time,  remark,  that  similar 
results,  are  occasionally  obtained  in  debilitated  and  cachectic 
subjects,  who  have  not  been  able  to  bear  blood-letting,  notwith- 
standing the  presence  of  an  intense  local  inflammation.  Upon 
comparing  the  facts  which  I  have  witnessed  in  my  own  practice, 
I  am  convinced  that  the  tolerance  depends  on  the  concurrence 
of  several  circumstances.  In  the  first  place,  the  medicine  in  con- 
siderable doses  is  less  emetic  than  in  small  doses ;  an  observation 
which  has  been  already  made  by  most  practitioners.  In  the  se- 
cond, the  habit,  which  accustoms  the  stomach  to  all  kinds  of 
substances,  seems  readily  formed  in  respect  of  this,  since  we 
find  that  vomiting  or  purging  almost  always  follows  its  adminis- 
tration on  the  first  day,  and  scarcely  ever  returns  after  the  se- 
cond. A  third  circumstance,  which  contributes  much  to  the 
prevention  of  vomiting,  is  the  ingestion  of  the  medicine  in  an 
agreeable  vehicle,  somewhat  aromatic,  and  moderately  diluted. 
The  intervention  of  a  period  of  two  hours  between  the  doses, 
also  contributes  to  the  same  result.  I  have  excited  copious  vo- 
miting by  means  of  the  tartar  emetic  given  in  doses  of  two  grains 
in  three  ounces  of  warm  water,  every  quarter  of  an  hour,  in  the 
commencement  of  a  bilious  peripneumony ;  while  the  same  pa- 
tient has  taken  it  on  the  following,  and  subsequent  days,  in  doses 
of  from  six  to  nine  grains,  in  the  manner  formerly  mentioned, 
without  experiencing  evacuations  of  any  kind.  When  the  fla- 
vour of  the  orange  leaf  is  disagreeable  to  the  patient,  I  give  the 
medicine  in  some  other  aromatic  infusion,  or  sweetened  emul- 
sion. When  it  occasions  too  copious  evacuations,  I  conjoin  with 
it,  as  I  have  stated  above,  a  small  quantity  of  opium — the  only 
corrective  of  its  operation  in  this  way  that  I  have  observed.  Cin- 
chona certainly,  does  not  act  in  this  way,  althopgh  it  has  been 
supposed  to  neutralize  the  tartar  emetic  in  the  bolus  ad  quar- 
tanam  of  La  Charite.*  There  is  no  doubt  that  bark,  as  well 
as  the  various  vegetable  infusions  usually  combined  with  tartar 
emetic,  more  or  less  decompose  this  medicine ;  but  this  change 
of  state  does  not  seem  in  any  way  to  affect  its  virtues,  since  we 

•  "  The  bolus  ad  quartanam  used  by  M.  Laennec  in  Necker  Hospital,  the 
same  I  presume  as  that  of  La  Charite1,  consists  of  one  grain  of  the  emetic  tar- 
tar, to  the  drachm  of  bark,  made  into  a  mass  by  extract  of  juniper."  (Ratier, 
Formul.  des  Hopitaux,  p.  193.) — Note  by  Dr.  Forbes. 


476  PNEUMONIA,    OR    PEHIPNEUMONIA. 

find  that  one  or  two  grains  dissolved  in  a  pint  of  vegetable  broth, 
lemonade,  decoction  of  tamarinds,  or  even  a  strong  decoction  of 
bark,  will  produce  very  effective  vomitings;  and  this  result  we 
also  observe  occasionally  from  the  bolus  above  mentioned,  espe- 
cially when  given  in  small  doses." 

1617.  "The  practice  above  detailed  is  not  in  reality  so  bold 
as  it  seems  at  first  sight;  since  only  one,  two,  or  three  grains  of 
the  tartar  emetic  are  given  at  one  dose — a  quantity  which  prac- 
titioners have  long  been  accustomed  to  administer.     The  medi- 
cine is,  moreover,  given  much  diluted,  and  is  thereby  deprived 
of  all  the  caustic  properties  which  it  possesses.    These,  be  it  re- 
membered, are  but  feeble,  since  we  know  it  only  then  produces 
pustules  when  it  is  applied  in  substance,*  and  retained  in  contact 
with  the  skin  for  two  or  three  days.     In  prescribing  the  medi- 
cine, we  are  careful  not  to  repeat  the  dose  if  the  preceding  has 
occasioned  any  ill  consequences,  a  circumstance  which  will  al- 
ways obviate  any  risk  from  its  employment  in  the  hands  of  the 
prudent  and  attentive  practitioner.     I  have  been  in  the  daily 
habit  of  employing  the  tartar  emetic  in  the  hospital  since  1816, 
and  more  particularly  since  1821;  and  I  do  not  think  any  one 
who  has  observed  my  practice,  have  ever  witnessed  any  ill  effect, 
of  consequence,  from  its  administration.     And!  I  can  give  a  like 
report  of  this  in  my  private  practice,  with  this  single  exception, 
that  I  have  observed,  in  the  latter,  vomiting  to  be  more  frequent 
than  in  the  hospital.     This  difference  of  result  has  appeared  to 
me  owing  to  the  patients  being  informed  by  their  nurses  or  their 
friends,  that  they  were  taking  tartar  emetic,  a  thing  which  I  have 
always  been  anxious  to  conceal  from  them."  Pages  249  to  258. 

1618.  We  have  thus  given  M.  Laennec's  experience  in  the 
use  of  the  tartrite  of  antimony  in  pneumonia — in  the  first  edition 
of  this  work  we  said  of  this  plan,  "  we  can  say  nothing  from  our 
own  experience. "  But,  since  that  period,  we  have  very  frequently 
used  the  tartrite  of  antimony  in  all  the  uncomplicated  acute  af- 
fections of  the  chest;  in  patients  of  all  ages,  and  with  the  most 
decided,  as  well  as  the  happiest  effects ;  but  not  in  the  large  doses 
of  either  Laennec,  or  Dr.  Tweedie.  We  do  not  think  large  doses 
essential,  as  we  constantly  found,  that  small,  nay,  in  some  in- 
stances, minute  doses,  answered  every  purpose.   We  have  given 
an  eighth  of  a  grain  every  hour  or  two  to  an  adult,  with  the  most 
marked  advantage;  and  to  young  children,  from  l-16th  to  l-32d 
part  of  a  grain,  with  equal  profit.    Dr.  Scudamore  says,  "I  have 
lately  had  many  opportunities  of  prescribing  tartar  emetic  on  the 
principle  of  treatment  I  have  described,  (Laennec,  &c.  method,) 
and  I  have  been  perfectly  satisfied  with  its  useful  agency ;  but  I 

•  "A  strong  solution  will  have  the  same  effect."— Dr.  Forbes. 


PNEUMONIA,   OR    FERIPNEUMONIA.  477 

have  usually  commenced  with  one  grain,  and  never  exceed  two 
grains,  for  the  first  twenty-four  hours ;  nor  found  it  necessary  to 
go  beyond  eight  in  the  progressive  quantity ;  except  in  one  case 
of  insanity,  in  which  sixteen  grains  were  given  daily  for  a  short 
time,  with  the  greatest  advantage.  In  the  quantity  of  two  grains, 
it  has  usually  produced  sickness  for  the  first  day  or  two,  but 
afterwards,  even  the  increased  doses  have  seldom  caused  any 
nausea." — Observations  on  M.  Laennec's  Method,  Sf-c.  p.  84. 

1619.  Beside  this  evidence  on  this  very  important  subject, 
we  have  collected  other,  which  strongly  confirms  the  utility  of 
this  remedy.     Thus,  Dr.  Tweedie*  bears  evidence  of  the  utility 
of  this  remedy  in  the  following  words: — "The  remedy,  how- 
ever, in  which  I  placed  most  confidence  in  inflammation  of  the 
lungs,  but  more  particularly  in  bronchitis,  either  as  an  auxiliary 
to  bleeding,  or  when  this  operation  was  not  justifiable  from  the 
length  of  time  the  local  symptoms  had  existed,  was  the  tartar 
emetic  in  doses  of  one  or  two  grains  every  second,  third,  or 
fourth  hour,  according  to  circumstances.  In  general  it  produced 
severe  vomiting  at  first,  the  violence  of  which  was  very  often 
lessened  by  the  addition  of  a  few  drops  of  laudanum  to  each 
draught;  but  when  the  tolerance  was  established,  it  was  most 
satisfactory  to  observe  the  gradual  decline  of  the  more  urgent 
symptoms  in  the  chest,  and  the  conviction  in  the  mind  of  the 
patient,  though  much  suffering  had  been  endured  from  the  vo- 
miting when  the  medicine  was  first  administered,  that  their 
amendment  was  to  be  ascribed  to  the  remedy." 

1620.  And  in  addition  to  this  we  will  give  an  account  of  the 
use  of  the  tartar  emetic  in  the  affection  we  are  treating,  as  well 
as  when  it  complicates  pleurisy,  from  the  fifth  volume  of  "  the 
Dublin  Hospital  Reports,  and  Communications  in  Medicine  and 
Surgery,"  as  it  is  every  way  confirmative  of  the  high  value  of 
this  remedy,  as  declared  by  Laennec  and  others,  in  such  affec- 
tions. 

1621.  "There  are  two  remedies  which  appear  to  have  a  pow- 
erful effect  in  removing  pneumonic  inflammation;  these  are  tartar 
emetic  and  the  combination  of  mercury  with  opium.   It  appears 
a  desideratum  to  determine  in  what  cases  each  of  these  remedies 
best  applies.     Our  experience  leads  us  to  conclude,  that  in  the 
uncomplicated  pneumonia,  occurring  in  robust  habits,  and  ac- 
companied by  inflammatory  fever,  the  first  of  these  remedies  is 
to  be  preferred." 

1622.  "  In  some  cases  we  find  that  the  first  dose  of  the  re- 
medy, (tartar  emetic,)  makes  the  patient  vomit  freely;  but  after 
a  few  more  doses  the  medicine  is  borne  well.  But  in  the  greatest 

•  Clinical  Illustrations,  &c.  p.  43. 


478  PLEURISY. 

number  of  cases  a  state  of  nausea,  without  vomiting,  is  kept  up, 
and  continues  several  days,  and  indeed  as  long  as  the  remedy  is 
administered." 

1623.  "  Sometimes  we  have  found  both  vomiting  and  purging 
to  follow  at  first,  but  to  subside  after  twenty-four  hours.     Dia- 
phoresis is  a  rare  effect;  and  we  have  often  witnessed  cases  where 
the  patient  was  taking  from  ten  to  twelve  grains  of  the  medicine 
daily,  without  vomiting,  purging  or  sweating ;  so  that  no  effect 
could  be  observed,  except  a  gradual  reduction  of  the  symptoms, 
and  stethoscopic  phenomena." 

SECT.  VII. — PLEURISY. 

1624.  This  disease  consists,  strictly  speaking,  of  an  inflamma- 
tion of  the  pleura;  and  its  pathognomonic  symptom,  agreeably  to 
common  -opinion,  is  a  pain  in  the  side,  which  is  augmented  by 
coughing,  and  a"  full  inspiration.     We  have  already  remarked, 
(par.  1544,)  that  in  inflammations  of  the  thoracic  viscera  and 
their  appendages,  that  we  had  no  indubitable  sign,  by  which  the 
inflammation  of  any  particular  portion  of  these  parts  is  indicated. 

1625.  Dr.  Cullen  makes  pleurisy,   (pleuritis,)  a  species  of 
pneumonia,  and  defines  it  as  "  a  pleuritic  pneumonia,  accompa- 
nied by  a  hard  pulse,  pungent  pain,  and  for  the  most  part  in  the 
side,*  particularly  increased  by  inspiration,  a  difficulty  in  lying 
on  the  affected  side,  cough  very  painful,  dry  in  the  beginning, 
afterwards  moist,  and  sometimes  bloody,  "t 

1626.  Now,  there  is  no  one  of  these  symptoms,  which  dis- 
tinctly point  out  an  insulated  inflammation  of  the  pleura;  while 
on  the  other  hand,  none  of  the  symptoms  detailed  by  authors, 
as  constituting  peripneumonia,  however  carefully  selected,  or 
earnestly  insisted  on,  declare,  that  either  the  lungs,  or  rather 
their  parenchyma,  are  involved,  to  the  exception  of  the  pleura. 
Yet  it  is  a  circumstance  not  to  be  doubted,  that  this  membrane 
may  be  inflamed  to  the  entire  exclusion  of  other  portions  of  the 
thoracic  contents. 

1627.  It  is  now,  however,  sufficiently  well  established  by 
frequent  post  mortem  examinations,  that  in  pneumonia,  it  is  the 
parenchyma  of  the  lungs  that  is  the  seat  of  the  inflammation  ; 
and  in  uncomplicated  pleurisy,  that  it  is  the  pleura  alone  that  is 

*  Nothing1,  perhaps,  shows  the  insufficiency  of  pain  in  the.  side,  as  a  distin- 
guishing mark  of  pleurisy  from  peripneumony,  or  other  thoracic  inflammation, 
than  that  authors  of  the  greatest  experience  differ  with  regard  to  the  side  the 
patient  lies  most  easily  upon.  Thus  Cullen  makes  "a  difficulty  of  lying  upon 
the  affected  side,"  as  an  essential  part  of  his  definition  of  pleuritis;  while 
Laennec,  Williams,  and  others  declare,  that  the  lying  upon  the  affected  side 
is  a  character  of  this  inflammation. 

t  Synop.  Vol.  II.  p.  102. 


PLEURISY.  479 

affected ;  but  the  same  observations  also  declare,  that  these  tis- 
sues are  very  much  oftener  combined  in  inflammation,  than 
found  separately  or  independently  in  this  condition. 

1628.  This  being  admitted,  it  would  seem  to  be  a  natural 
consequence,  that  this  specific  location  of  inflammation  should 
be  marked  by  some  constitutional  or  characteristic  symptoms — 
but  this  is  not  exactly  so.     For  had  this  been  the  case,  the  re- 
searches of  the  more  modern  pathological  inquirers,  would  cer- 
tainly have  detected  them,  provided  we  do  not  include  ausculta- 
tion among  the  means  by  which  pleurisy  or  peripneumony  may 
be  known.* 

1629.  Pinel  and  Bricheteau  have  attempted  the  diagnoses  o£ 
pleurisy  and  pneumonia;  and  with  as  much  success  perhaps  as 
the  subject  is  capable  of.     We  shall  therefore  quote  it,  from  the 
Diet,  des  Scienc.  Med.  torn.  43,  p.  202,  reserving  to  ourselves 
the  right  of  making  a  few  observations. 

1630.  "  The  diagnostic  of  pleurisy  is  sometimes  difficult  to 
establish,  especially  in  children  and  the  insane,  and  in  those  who 
habitually  breathe  with  difficulty.  Pneumonia,  from  its  location, 
resembles  pleurisy  more  than  any  other  affection,  especially  when 
the  pleura  of  the  lungs  is  also  involved.   We  must  therefore  com- 
pare the  respective  symptoms,  to  understand  the  difference  be- 
tween them.     Pleurisy  is  attended  by  an  acute  superficial  pain, 
which  is  increased  by  percussion,  by  lying  on  the  affected  side, 
by  inspiration  and  coughing.     In  pneumonia,  on  the  contrary, 
the  pain  is  deep-seated,  obtuse,  with  a  sense  of  suffocation,  and 
decided  oppression.     In  pleurisy,  the  cough  is  commonly  dry; 
the  pulse  hard,  contracted,  and  frequent.     In  pneumony,  the 
cough  is  moist,  the  pulse  often  soft ;  in  pleurisy,  we  rarely  see 
blood  mixed  with  the  limited  expectoration ;  in  pneumony,  it  is 
very  common,  and  the  expectoration  is  very  abundant."     We 
believe  the  above  to  be  as  correct  as  any  history  that  has  been 
given  of  these  two  affections ;  but  it  will  be  seen  as  we  proceed, 
that  the  distinctive  marks  are  by  no  means  constant. 

1631.  Fever  is  a  constant  attendant  upon  both  peripneumony 
and  pleurisy ;  though  authors,  in  attempting  their  diagnoses, 
make  it  in  the  latter  more  intense  than  in  the  former.  The  pulse 
in  pleurisy,  as  we  have  just  stated,  is  declared  to  be  always  hard 
and  resisting.     This  circumstance  is  so  uniform  that  it  has  been 
insisted  on  by  Galen  and  many  others,  (Diet,  des  Scien.  Med. 
vol.  43,  p.  195,)  as  pathognomonic,  and  is  strongly  enforced  by 
Baglivi;  nay,  he  has  said,  that  from  this  symptom  alone  he  would 
not  fear  to  pronounce  that  the  disease  was  an  inflammation  of  the 
pleura.  "Pulsus  durities  est  signum  fere  infallibile  omnium  pleu- 

•  See  the  Anatomical  Characters  of  Pleurisy,  p.  492. 


480  PLEURISY. 

ritidum.  Si  duritietn  in  pulsu  deprehenderis,  quamvis  reliqua 
signa  non  adsint,  procerto  habeas  patientem  laborare  pleuritide." 
While  in  peripneumony  the  pulse  is  said  to  be  more  generally 
soft  and  undulating.*  These  two  conditions  seem  to  be  acknow- 
ledged by  almost  all  writers;  yet  exceptions  so  frequently  occur, 
as  to  render  them  extremely  uncertain  guides.  Besides,  the  de- 
grees of  fever  must  be  determined  with  difficulty,  as  we  have  no 
certain  means  to  measure  them;  nor  have  we  any  other  method 
than  the  touch,  to  ascertain  the  degree  of  force  of  the  pulse;  and 
the  result  of  attempts  to  determine  this  state  by  several  indivi- 
duals in  any  given  number  of  cases  at  one  and  the  same  time, 
would,  in  many  of  these  instances,  be  very  discrepant. 

1632.  But  this  fortunately  can  lead  to  but  little  practical  error, 
since  it  must  be  by  the  absolute,  and  not  the  comparative  state 
of  the  pulse,  that  our  prescriptions  are  to  be  regulated — for  if  the 
pulse  be  tense  and  resisting,  we  must  bleed,  whether  the  tissue 
involved  be  the  pleura,  or  the  air-cells  of  the  lungs  themselves. 
Nor  do  we  hesitate  to  believe,  that  the  pulse  may  differ  in  cha- 
racter, as  one  or  other  of  the  thoracic  tissues  may  be  affected; 
but  as  "  the  degree  of  fever,"  or  "  the  hardness  or  softness  of  the 
pulse,"  can  have  no  absolute  standard,  by  which  either  can  be 
determined  with  unerring  precision,  the  condition  of  the  pulse 
in  the  two  affections,  cannot,  nor  should  not,  be  compared  with 
each  dther;  therefore,  much  must  always  be  left,  (whether  right 
or  wrong,)  to  the  medical  attendant,  either  to  form  his  diagnosis, 
or  to  regulate  the  nature  and  extent  of  the  remedial  means. 

1633.  In  pleurisy,  the  breathing  is  less  laborious  and  oppress- 
ed than  in  peripneumony;  for  the  patient  for  the  most  part  can 
lie  down;  whereas,  in  the  other,  it  is  so  confined,  that  he  is 
obliged  sometimes  to  sit  up,  to  prevent  suffocation.  In  pleurisy, 
the  breathing  is  also  less  frequent  than  in  peripneumony. 

1634.  Laennec  declares  that  "the  dyspnoea  is  very  variable 
as  to  intensity.  In  some  cases  the  patients  are  unconscious  of  its 
existence,  though  it  is  perceptible  to  the  bystanders;  and  some- 
times it  is  equally  unobserved  by  both;  in  other  cases  it  is  ex- 
tremely urgent,  and  speedily  reaches  the  degree  of  impending 
suffocation.     When  the  dyspnoea  is  not  severe,  it  appears  to  be 
rather  occasioned  by  the  pain  of  the  side,  which  moderates  the 
inspiration,  than  by  the  compression  of  the  lungs  by  the  effused 
fluid;!  since  we  find  that  it  commonly  ceases  after  a  few  days 

*  Morgagni  declares  it  to  be  rather  slower  in  peripneumony  than  natural; 
and  thinks  this  circumstance  alone  may  betray  an  inflammation  of  the  lungs. 
Epist.  xxi.  art.  13. 

f  "  The  fever  ceases  with  the  stitch,  and  the  patient  finding  his  appetite  and 
strength  return,  fancies  himself  cured,  though  there  still  exists  an  abundant 
extravasation  in  the  chest,  which  cannot  be  got  rid  of  for  a  long  period,  even 


PLEURISY.  481 

with  the  pain  and  other  symptoms  of  acute  inflammation,  though 
at  this  time  the  effusion  is  more  copious  than  before."  Laennec, 
p.  443. 

1635.  In  pleurisy,  as  a  general  rule,  there  is  a  more  acute  and 
distinctly  located  pain,  which,  when  it  exists,  is  sure  to  be  aug- 
mented by  coughing,  or  by  a  deep  inspiration.     But  this  symp- 
tom is  by  no  means  constant,  or  always  to  be  relied  on.     Mor- 
gagni  gives  a  number  of  remarkable  proofs  of  this  fad'.*  Pain  is 
sometimes  felt  on  both  sides  of  the  chest  at  the  same  time,  but 
this  does  not  necessarily  constitute  a  double  pleurisy.    The  pain 
when  felt  is  generally  about  the  neighbourhood  of  the  nipple. 
Laennec  confirms  the  opinion  of  Morgagni,  that  the  stitch  is  not 
a  constant  symptom,  being  absent,  sometimes,  in  the  most  acute 
cases.    It  sometimes  shifts  its  seat  to  the  other  side,  but  without 
a  transfer  of  the  inflammation.     Sometimes  the  painful  stitch  is 
on  the  side  opposite  to  the  inflammation.   Laennec  does  not  think 
that  pressure  upon  the  intercostal  spaces  always  excites  pain,  un- 
less a  rheumatic  affection  be  present.   While  Andral,  Broussais, 
and  Forbes,  think  it  far  from  unusual,  t 

1636.  In  pleurisy,  there  is  an  absence  of  that  sense  of  weight 
and  distention  throughout  the  chest,  that  sometimes  attends  pe- 
ripneumony ;  and  though  this  is  not  a  constant  symptom  in  the 
latter,  yet  it  is  never  perhaps  felt  in  the  former.  But  on  this  last 
distinction  much  reliance  should  not  be  placed,  since  Morgagni 
informs  us  that  it  was  not  present  in  the  case  of  Coralli,  who 
died  of  a  short  illness,  from  an  inflammation  of  his  lungs;  for  he 
says,  that  "when  the  thorax  was  opened,  we  found  the  upper 
part  of  the  lungs  on  the  right  side,  tumid,  hard,  and  stuffed  up 
with  blood,"  loc.  cit.  art.  12.  Yet  we  have  witnessed  this  sense 
of  weight  in  a  number  of  instances  of  peripneumony,  though,  as 
just  observed,  it  is  not  a  constant  symptom. 

1637.  The  cough  in  pleurisy  is  more  constant  and  severe, 
perhaps,  than  in  peripneumony;  it  is  usually  dry  in  the  begin- 
ning, and  does  not  become  otherwise,  unless  the  force  of  the  dis- 
ease be  abated  by  prompt  and  active  antiphlogistic  means,  or  un- 
til the  disease  has  run  its  course  for  several  days  without  oppo- 
sition, or  with  but  feeble  applications;  in  which  cases,  expecto- 
ration sometimes  takes  place;  but  the  sputa  are  tenacious,  nearly 

should  nothing  interfere  to  check  the  progress  of  absorption.  And  the  physi- 
cian who  does  not  explore  the  chest,  must  fall  into  the  same  error  as  his  pa- 
tient." Ib.  p.  444. 

•  Epist.  xxi.  art.  23. 

t  So  far  from  pain  in  any  part  of  the  thorax  being  a  constant  attendant  upon 
pleurisy,  that  Pinel,  Baglivi,  and  others  say,  that  it  may  inflame  and  even  sup- 
purate, without  the  patient  experiencing  any  sensation  that  would  characterize 
this  affection.  This  condition  of  the  pleura  gave  rise  to  that  species,  called 
"  the  latent,  or  occult  pleurisy." — Diet,  des  Sciences  Med.  art.  Plturisie,  p.  192. 

61 


482  PLEURISY. 

transparent,  and  resemble  very  much  a  thin  solution  of  glue. 
Mucus  is  never  spat,  unless  the  pleurisy  be  complicated  with 
bronchial  inflammation.  Blood  does  not  unfrequently  accompany 
the  sputa  in  every  form  of  pneumonia;  it  is  therefore  not  cha- 
racteristic of  pleurisy;  indeed  we  believe  it  never  happens  in 
pure  pleuritis.  Pleurisy  is  almost  always  accompanied  by  a  se- 
vere lancinating  pain  upon  coughing,  or  upon  a  deep  inspiration, 
as  we  just  have  noticed ;  whereas,  this  is  rarely  the  case  when 
the  substance  of  the  lungs  is  the  seat  of  the  inflammation.  Pain 
in  this  case  is  almost  entirely  wanting,  or  is  only  obscurely  per- 
ceived in  the  course  of  the  sternum,  or  spine.  The  flushing  of 
the  face  does  not  take  place  so  early,  nor  is  it  so  intense  in  pleu- 
risy, as  in  peripneumony;  yet  towards  the  latter  period  of  the 
disease,  where  the  inflammation  has  been  less  obedient  to  reme- 
dies than  usual,  or  where  it  had  been  neglected,  or  timidly  treat- 
ed in  the  commencement,  and  especially  in  persons  beyond  the 
meridian  of  life,  the  cheeks  have  an  intensely  red  and  circum- 
scribed circle  almost  constantly  upon  them.  This  condition  is 
almost  always  accompanied  with  a  disposition  to  coma,  a  tena- 
cious expectoration,  and  suppressed  or  imperfect  cough,  and  a 
very  slow  respiration. 

1638.  It  is  perhaps  at  this  moment,  that  the  parenchyma  of 
the  lungs  may  become  implicated  in  the  inflammation,  and  the 
disease  now  becomes  a  pleuro-pneumonia.     The  urine  now  is  al- 
most sure  to  become  sparing,  and  very  high-coloured ;  which 
constantly  augurs  a  severe  and  dangerous  state  of  the  disease. 
In  general  the  patient  lies  easiest  on  the  side  in  pleurisy,  and  on 
the  back  in  peripneumony. 

1639.  But  notwithstanding  every  attempt  to  distinguish  the 
two  affections  of  pleurisy  and  peripneamonia  from  each  other, 
much  obscurity  still  prevails  upon  the  subject.*     This  appears 
to  be  admitted  by  all  the  best  practical  writers,  and  the  most  ex- 
perienced pathological  anatomists.  Morgagni  is  perhaps  less  sa- 
tisfactory upon  these  points,   than  upon  almost  any  other   of 
which  he  treats ;  to  be  convinced  of  this,  we  need  but  consult 
his  twentieth  and  twenty-first  letters.     Laennec  makes  the  fol- 
lowing important  remarks.   "  When  pleurisy  is  simple,  we  find 
no  sign  whatever  of  inflammation  of  the  pulmonary  tissue,  even 
in  the  vicinity  of  the  most  inflamed  portions  of  the  pleura;  only 
we  find  the  substance  of  the  lungs  in  such  cases,  more  dense  and 
less  crepitous,  by  means  of  the  compression  produced  by  the  ef- 

•  We  must  here  be  understood  to  mean,  by  any  of  the  constitutional  symp- 
toms enumerated  as  attending  upon  the  two  affections — for  it  is  now  conceded 
that  the  stethoscope  is  able  to  distinguish  them  with  great  certainty;  and  con- 
sequently this  very  circumstance  offers  strong  Inducements  to  the  study  of  aus- 
cultation. 


FLEumsr.  483 

fused  fluids.  If  the  extravasation  has  been  very  great,  the  lung 
becomes  flattened  and  completely  flaccid  ;  it  ceases  to  contain  air, 
and  consequently  to  crepitate;  its  vessels  are  compressed  and 
contain  little  blood ;  and  the  bronchia,  (and  sometimes  even  the 
largest  trunks,)  are  evidently  rendered  smaller.  The  peculiar 
texture  of  the  lung,  however,  is  still  very  perceptible,  there  be- 
ing no  trace  of  obstruction  like  that  produced  in  peripneumony; 
and  if  air  be  blown  into  the  bronchia,  the  lungs  become  expand- 
ed more  or  less  completely."  p.  428. 

1640.  This  exposition,  will  we  trust,  tend  to  lessen  the  re- 
ports of  the  wasting  of  the  lung,  in  post  mortem  examinations. 
On  this  point  we  have  been  led  by  the  reduced  size  of  the  lung, 
into  the  belief,  where  there  were  large  accumulations  of  sero-puru- 
lent  fluids  in  the  thorax,  that  it  was  wasted  to  the  size  we  found 
it;  whereas,  it  is  much  more  than  probable,  that  in  these  several 
instances,  the  lungs  were  only  compressed  by  the  weight  of  the 
fluid  which  was  surrounding  them,  as  appears  to  be  proved  by 
Laennec. 

1641.  Laennec  alone  is  satisfactory  upon  pneumonia;  .and  in 
his  account  of  pleurisy,  he  has  detailed  minutely,  and  we  pre- 
sume faithfully,  the  anatomical  characters  of  this  disease,  and  of 
which  'we  shall  make  free  use.     In  doing  this,  we  are  convinced 
we  shall  be  performing  a  useful  and  an  acceptable  office,  as  all 
his  pathological  researches  are  of  the  utmost  value  ;  and  we  will 
here  take  occasion  to  recommend,  the  careful  study  of  his  invalu- 
able work  upon  the  diseases  of  the  chest. 

1642.  Laennec*  divides  pleurisy  into,  1.  Simple  acute  pleu- 
risy.    2.  Acute  haemorrhagic  pleurisy.     3.  Chronic  pleurisy. 
4.  Contraction  of  the  chest  consequent  to  pleurisy.     5.  Circum- 
scribed or  partial  pleurisy.      6.    Latent  pleurisy.     7.    Pleuro- 
pneumonia.     8.  Emphysema.  But  we  do  not  think  it  necessary 
to  follow  these  divisions  in  detail ;  we  shall  endeavour  to  incor- 
porate the  most  important  parts  under  one  general  title, 

Of  Simple  »/2cute  Pleurisy. 

1643.  "  The  anatomical  characters  of  pleurisy,  are  drawn  from 
the  state  of  the  pleura,  and  the  alterations  and  augmentations 
of  the  secretion  which  always  accompanies  the  inflammation 
of  this,  and  of  all  serous  membranes."^ 

1644.  "The  pleura  in  the  state  of  inflammation  presents  a  punc- 
tuated redness;  as  if  one  had  traced  with  a  pencil  upon  the  pleura, 

*  Diseases  of  the  Chest,  p.  421,  et  seq. 

f  We  have  put  in  italics,  throughout  our  quotations  from  Laennec,  the  points 
most  worthy  of  observation  in  our  estimation,  and  which  deserve  to  be  insisted 
on,  either  as  remarkable  facts,  or  as  important  practical  observations. 


484  PLEURISY. 

an  infinity  of  small  bloody  spots  of  a  very  irregular  figure,  and 
very  close  to  one  another.  These  red  points  occupy  the  whole 
thickness  of  the  membrane,  and  have  small  intermediate  portions 
retaining  the  natural  white  colour." 

1645.  "  Inflammation  of  the  pleura  is  always  accompanied 
by  an  extravasation  on  its  internal  surface,  and  which,  may 
be  considered  as  the  species  of  suppuration  proper  to  serous 
membranes.      This  extravasation  appears  to  commence  with 
the  inflammation  itself.     It  consists,  usually  at  least,  and  in 
my  opinion  always  of  two  very  different  matters:  the  one  of  a 
firmer,  semi-concrete  consistence,  is  usually  termed  false  mem- 
brane, or  coagulable  lymph;  the  other  very  thin  and  watery,  is 
called  serosity  or  sero-purulent  effusion.     Both  of  these  exhibit 
great  varieties  of  character." 

1646.  "Occasionally,  and  especially  when  the  effused  fluid 
is  in  large  quantity,  the  false  membranes    becomes    separated 
from  the  pleura,  either  wholly  or  in  part,  and  float  loosely  in  the 
serum." 

1647.  "The  effused  fluid  which  attends  the  formation  of  the 
false  membranes,  is  of  a  light  yellow  colour,  transparent,  or  only 
a  little  opaque  by  filaments  of  the  false  membrane.   It  is  generally 
without  smell  in  acute  pleurisy;  sometimes  however  it  is  offen- 
sive.    The  serum  is  sometimes  very  abundant,  and  the  membra- 
nous exudation  very  small,  and  the  reverse.     In  general,  the 
thickness  and  extent  of  the  membranous  exudation,  is  in  pro- 
portion to  the  inflammation.  In  weak  leuco-phlegmatic  habits, 
the  quantity  of  serum  on  the  contrary  is  great;  and  the  disease 
seems  to  pass  insensibly  into  hydrothorax.    Sometimes  the  con- 
tiguous surfaces  of  the  pleura  are  united  without  any  serous  effu- 
sion." 

1648.  "  In  cases  of  peripneumony  also,  even  in  those  which 
are  slight  and  partial,  we  sometimes  find  the  pleura  pulmonalis 
in  the  vicinity  of  the  inflamed  part,  invested  by  a  false  mem- 
brane of  small  extent." 

1649.  "  I  think  it  necessary  to  notice  a  common  error  respect- 
ing the  period  at  which  the  pleuritic  effusion  takes  place.     Many 
imagine  that  it  does  not  occur  until  after  a  certain  time,  and  even 
some  days;  and  it  is  this  notion,  no  doubt,  that  has  given  rise  to 
the  common  expression  of  pleurisy  terminated  by  effusion. 
These  opinions  are  incorrect.    I  have  several  times  observed  all 
the  physical  signs  of  effusion — that  is,  aegophonism  and  absence 
of  respiration  and  sound  on  percussion — in  the  course  of  an  hour 
after  the  invasion  of  the  disease,  and  I  have  seen  the  side  ob- 
viously dilated  at  the  end  of  three  hours.     On  the  other  hand, 
I  do  not  remember  to  have  met  with  a  single  case  in  which  the 
effusion  was  doubtful,  (under  the  stethoscope,)  during  the  first  and 


PLEURISY.  485 

second  day,  and  distinct  in  the  succeeding  days.  I  am  convinced, 
that  the  effusion  of  serum  is  contemporaneous  with  the  in- 
flammation in  all  serous  membranes." 

1650.  We  beg  the  reader's  attention  to  the  several  highly  va- 
luable practical  facts  contained  in  the  above  extract,  as  it  will 
necessarily  lead  him  to  oppose  this  disease  by  decisive  mea- 
sures in  its  commencement;  for  it  is  at  this  time  only  it  can  be 
done  with  all  the  advantage  that  the  interest  of  the  patient  re- 
quires.    From  the  observations  of  Laennec  it  is  declared,  that 
the  membranous  exudation  is  in  proportion  to  the  degree  and  ex- 
tent of  the  inflammation;  to  diminish  this  disposition  then,  be- 
comes a  very  important  indication — the  mode  of  fulfilling  it,  is 
at  once  obvious;  namely,  by  blood-letting  and  other  evacuations. 

1651.  Another  very  important  part  of  the  history  of  the  in- 
flammation of  the  pleura,  is,  that  the  effusion  of  serum  is  coin- 
cident with  the  inflammation — this  being  the  case,  it  will  seem 
to  follow,  that  this  will  also  be  in  proportion  to  the  extent  and 
duration  of  the  inflammation;  consequently,  a  new  and  power- 
ful motive  for  the  employment  of  active  measures,  in  the  form- 
ing state,  (if  possible,)  of  the  disease,  presents  itself.     The  pa- 
thological fact,  as  regards  the  economy  of  all  serous  membranes 
when  labouring  under  inflammation,  is  not  only  valuable  in  a 
practical  point  of  view,  but  it  also  reconciles  us  to  those  histo- 
ries of  peritoneal  inflammations,  in  which  the  effused  fluid  was 
so  enormously  great,  in  a  short  space  of  time,  as  almost  to  excite 
disbelief.     As  this  subject  is  highly  interesting,  as  well  as  prac- 
tically important,  we  are  certain  we  shall  receive  the  reader's 
thanks  for  dwelling  so  much  upon  it;  especially  as  it  is  almost 
untrodden  ground.     To  Laennec  then,  is  the  profession  largely 
indebted  for  his  valuable  pathological  contributions,  particularly 
upon  so  important  a  portion  of  the  body  as  the  chest,  the  diseases 
of  which  are  no  less  numerous  than  severe,  and  yet  none,  per- 
haps, so  little  understood.     The  method  pointed  out  by  him,  by 
which  the  various  conditions  of  the  thorax  and  its  viscera  are  as- 
certained, is  not  less  certain  than  simple;  and  we  earnestly  re- 
commend the  study  of  the  exploration  of  the  chest  by  means  of 
the  stethoscope  and  purcussion,  to  every  practitioner  of  medicine 
who  holds  his  own  comfort  and  reputation,  or  the  welfare  of  his 
patients,  in  any  degree  of  estimation.     But  to  return — we  shall 
now  give  Laennec's  explanation  of  the  conversion  of  the  "false 
membranes  produced  in  pleurisy,  into  a  true  serous  tissue,  like 
that  of  the  pleura." 

1652.  "  This  change  is  produced  in  the  following  manner;  the 
serous  effusion  which  accompanied  the  membranous  exudation  is 
absorbed,  the  compressed  lung  expands,  and  the  false  membrane 
that  invests  it  and  the  costal  pleura  becomes  united  into  one  sub- 


486  PLEURISY. 

stance.  By  and  by,  this  substance  becomes  divided  into  layers 
pretty  thick  and  opaque,  which  are  separated  by  a  very  small 
portion  of  serosity.  About  this  time  blood-vessels  begin  to  make 
their  appearance  in  it;  the  first  rudiments  of  which,  have  the  as- 
pect of  irregular  lines  of  blood,  much  larger  than  the  vessels 
that  are  to  take  their  place.  The  blood  seems  as  if  it  had  been 
forced  into  the  substance  of  the  false  membrane  by  a  strong  in- 
jection ;  and  we  find  the  corresponding  portions  of  the  pleura 
redder  than  elsewhere,  and  as  it  were  spotted  with  blood.  After 
a  time  the  pseudo-membranous  layers  become  thinner  and  less 
opaque ;  the  lines  of  blood  assume  a  cylindrical  shape,  and 
ramify  in  the  manner  of  blood-vessels,  but  still  preserving 
their  augmented  diameter.  On  minutely  examining  them  at 
this  stage,  we  find  their  external  coat  consisting  of  blood  scarcely 
yet  concrete,  and  very  red ;  within  this  there  is  a  sort  of  mould, 
or  rounded  substance,  whitish  andfibrinous,  and  formed  evi- 
dently of  concreted  fibrin,  perforated  in  its  centre,  already 
permeable  to  the  blood,  and  evidently  containing  it.  Eventu- 
ally, the  layers  of  the  false  membrane  become  quite  transparent, 
and  nearly  as  thin  as  those  of  the  ordinary  cellular  tissue  and  the 
blood-vessels  resemble  in  every  respect  those  which  ramify  on 
the  inner  surface  of  the  pleura." 

1653.  "Jlfter  they  have  attained  this  stage,  whatever  may 
be  their  extent,  they  do  not  in  general,  affect  the  health" 
This  is  a  curious  fact ;  especially  as  it  is  at  once  at  variance  with 
all  our  preconceived  notions  and  apprehensions  upon  this  subject. 
He  further  adds,  "  the  respiration  even,  except  in  some  parti- 
cular cases,  does  not  suffer  from  their  presence.     They  pos- 
sess in  fact,  all  the  characters  of  the  natural  serous  tissues,  being 
capable  of  exhalation  and  absorption  like  them,  and  often  con- 
taining in  cases  of  dropsy,  a  considerable  quantity  of  effused  se- 
rum.    They  sometimes  even  inflame,  and  in  this  case  become 
invested  with  false  membranes  similar  to  what  they  them- 
selves had  originally  been — this  is  however  very  rare." 

1654.  M.  Laennec  in  the  conclusion  of  this  very  interesting 
history  of  the  production  of  new  membranes,  makes  a  practical 
remark,  which  is  contrary  to  the  popular  opinion  on  the  subject 
of  pleurisy.     He  says,  "it  is  found,  that  in  cases  of  a  second  at- 
tack of  pleurisy  in  a  person  whose  lungs  adhere  to  the  pleura 
from  the  effects  of  the  first,  the  inflammation,  albuminous  exu- 
dation and  sero-purulent  effusion,  do  not  invade  the  adherent 
parts;  inasmuch  that  we  may  lay  it  down  as  a  principle,  that  the 
severer  has  been  the  attack  of  pleurisy,  the  less  likely  is  a  re- 
turn of  the  same  disease.     The  following  remarks  on  the  con- 
dition of  the  chest  after  inflammation  is  removed,  are  curious  and 
interesting. 


PLEURISY.  487 

1655.  "I  have  known  cases  in  which  the  thoracic  resonance 
and  respiratory  sound  have  not  completely  returned  before  the 
expiration  of  six  months,  though  the  patients,  judging  from  the 
continuance  of  the  pain  and  fever,  asserted  that  they  had  only 
been  ill,  in  all,  four  or  five  days.     It  is  very  rare  even  in  the 
mildest  cases  of  acute  pleurisy,  and  in  which  the  inflammation 
is  the  most  speedily  checked,  for  the  effusion  if  at  all  consi- 
derable, to  be  completely  absorbed  and  the  false  membrane 
converted  into  cellular  substance,  in  less  than  a  month;  most 
commonly  this  is  not  affected  in  less  than  two  or  three." 
p.  444.     These  facts  are  of  great  value,  and  deserve  to  be  borne 
in  mind  by  every  practitioner. 

1656.  In  addition  to  the  common  or  local  symptoms  of  acute 
pleurisy,  the  physical  signs  are  next  in  importance.     This  part 
of  the  pathology  of  the  chest,  is  largely  indebted  to  a  number  of 
living  cultivators  of  the  auscultic  branch  of  medicine,  as  Andral, 
Forbes,  Williams,  &c.  but  to  none  so  eminently  as  to  the  la- 
mented and  amiable  Laennec.    It  seems  to  be  admitted  by  com- 
mon consent,  that  he  was  the  most  accomplished  of  those  who 
made  mediate  auscultation  a  study.  His  facts  are  never  disputed; 
nor  his  veracity  impugned — what  he  declares  to  be  the  result  of 
his  own  observations,  no  one  hesitates  to  believe.     He  has  ef- 
fected, we  must  repeat,  an  entire  revolution  in  the  study  of  the 
diseases  of  the  chest,  by  the  extent,  and  accuracy  of  his  patho- 
logical details ;  and  has  pointed  out  a  certain,  and  unfailing  me- 
thod of  exploring  the  healthy,  and  pathological  condition,  not 
only  of  the  pulmonary  organs,  but  of  the  heart,  and  larger  blood- 
vessels themselves.     We  cannot  feel  it  necessary  to  make  an 
apology  for  the  extensive  use  we  have  made  of  this  justly  cele- 
brated physician's  work,  as  it  is  in  the  hands  of  but  few,  as  we 
are  confident,  that  by  doing  so,  we  are  but  promulgating  some 
of  the  most  valuable  practical  discoveries  of  modern  times.    We 
shall,  therefore,  without  hesitation,  detail   the  more  material 
points  he  has  insisted  on,  in  his  account  of  the  "  Physical  Signs 
of  Acute  Pleurisy."     He  says — 

1657.  "  As  soon  as  effusion  takes  place,"  (and  he  has  declared, 
as  we  have  observed  above,  that  this,  (the  effusion,)  is  contem- 
poraneous with  the  inflammation  of  the  pleura,)  "the  natural 
sound  of  the  chest  on  percussion,  fails  over  the  whole  space  oc- 
cupied by  the  fluid.     From  this  result  simply,  we  could  not  in- 
deed be  certain  that  the  disease  is  pleurisy  or  peripneumony ; 
though  the  common  symptoms,  general  and  local,  must  assist  us 
in  making  the  distinction."     "But,"  he  adds,  (t  in  the  case  of 
pleurisy,  it  frequently  happens,  that,  in  the  course  of  a  few 
hours  from  the  attack,  the  dull  sound  exists  over  the  whole 
affected  side,  or,  at  least,  over  its  lower  half— a  thing  which 


488  PLEURISY. 

is  never,  or  almost  never,  observed  in  peripneumony.  But 
mediate  auscultation  furnishes  us  with  much  more  certain  means 
of  discriminating  these  two  diseases,  and  enables  us  to  ascertain 
with  precision,  not  merely  the  existence  of  the  effusion,  but  its 
quantity.  The  signs  by  which  the  cylinder  effects  this,  are,  1st, 
the  total  absence,  or  great  diminution,  of  the  respiratory  sound  ; 
and  2d,  the  appearance,  disappearance,  and  return  of  aegopho- 
nism." 

1658.  "When  the  pleuritic  effusion  is  very  copious  from  its 
very  commencement,  the  sound  of  respiration  is  then  totally 
absent,  through  the  whole  of  the  side  affected,  except  in  a 
space  of  three  fingers?  breadth  along  the  vertebral  column  ; 
where  it  is  still  heard,  though  less  strongly  than  on  the  other 
side.     This  complete  disappearance  of  respiration  after  the  ex- 
istence of  disease  for  a  few  hours,  is  quite  pathognomonic  of 
pleurisy  with  copious  effusion,  whether  there  exists  pain  of 
the  side  or  not.     In  peripneumony,  the  disappearance  of  re- 
spiration is  gradual,  and  is  perceived  to  be  unequal  in  dif- 
ferent parts  of  the  chest."  p.  436. 

1659.  "  In  pleurisy,  with  copious  effusion,  on  the  contrary, 
the  loss  of  the  respiratory  murmur  is  sudden,  equable,  uni- 
form, and  so  complete,  that  no  effort  of  respiration  can  ren- 
der it  perceptible."  p.  437. 

Prognosis. 

1660.  Pleurisy,  like  all  the  other  phlegmasia?,  may  terminate 
variously;  and  especially,  like  peripneumony — we  have  already 
noticed  these  terminations  at  par.  1571.     As  a  general  rule,  this 
disease  is  more  severe  and  threatening  in  the  plethoric  and  ro- 
bust, than  in  the  more  feeble ;  and  it  is  particularly  dangerous 
in  constitutions  that  have  been  impaired  by  hard  drinking. 

1661.  Women  who  are  not  pregnant,  support  this  disease 
better  than  males;  but  if  pregnant,  it  is  always  of  doubtful  issue. 
This  was  perhaps  first  observed  by  Hippocrates;  and  the  truth 
of  the  observation  has  been  constantly  confirmed  by  all  subse- 
quent writers.  Relapses  of  pleurisy  are  always  alarming;  as  they 
are  almost  always  fatal.     Nor  is  this  of  difficult  explanation;  the 
disease  recurs  at  a  moment,  in  which  the  system  is  almost  ex- 
hausted of  its  powers,  and  altogether  incompetent  to  support  the 
further  depletion,  that  is  necessary,  to  subdue  the  new  accession 
of  disease. 

1662.  A  diarrhoea  supervening  on  the  fourteenth  day,  is  fa- 
vourable, agreeably  to  Van  Swieten ;  but  one  occurring  at  the 
commencement  of  the  disease,  is  bad,  according  to  Triller.   But 
neither  of  these  observations  have  been  confirmed  by  our  own 


PLEURISY.  489 

experience,  for  we  have  constantly  found,  that  a  diarrhoea  of  any 
extent,  at  any  period,  was  always  unfavourable  in  pleurisy ;  and 
this  has  appeared  to  us  to  be  especially  so,  where  the  disease  re- 
quired large  losses  of  blood  ;  or,  in  other  words,  where  the 
pleura,  from  the  great  severity  of  the  symptoms,  appeared  to  be 
extensively  involved  in  inflammation.  The  diarrhoea  in  these 
cases  seemed  to  injure  the  recuperative  powers  of  the  system, 
without  diminishing  the  local  affection.  We  may  further  remark, 
that  the  occurrence  of  diarrhoea  is  by  no  means  frequent,  where 
the  cure  of  pleurisy  is  attempted  early,  and  by  adequate  means ; 
for,  as  the  disease  is  very  much  taken  out  of  the  hands  of  na- 
ture, the  system  has  no  need,  if  we  may  so  express  ourselves, 
of  having  recourse  to  a  critical  discharge  on  the  fourteenth  day ; 
nor  is  it  so  liable  to  suffer  from  a  metastasis  in  the  early  part 
of  it. 

1663.  Our  own  experience  then,  is  in  strict  conformity  with 
that  aphorism  of  Hippocrates,  which  declares,  "  A  pleuritide 
aut  peripneumoniai  detento,  alvi  profluvious  superveniens,  ma- 
lum;"  and  the  cause  of  its  being  bad,  perhaps  is,  that  it  declares 
a  metastasis,  and  not  a  critical  effort. 

1664.  If  the  breathing  be  laborious,  or  orthpnosa  be  present, 
it  is  always  bad  in  proportion  to  its  extent — hence,  a  free  respi- 
ration is  constantly  considered  as  a  favourable  sign,  especially 
if  it  have  been  procured  by  adequate  depletion.     If  the  disease 
be  attended  with  free  expectoration,  it  may  be  considered  as 
presenting  less  risk;  while  its  absence  must  always  be  considered 
as  a  bad  sign ;  these  circumstances  have  been  acknowledged  as 
truths  by  the  experience  of  every  body  since  the  time  of  Hip- 
pocrates. 

1665.  The  urine  also  furnishes  us  with  signs  of  pretty  certain 
import — thus,  a  small  quantity  without  deposition,  is  bad  ;  an 
abundant  one  with  sediment,  is  favourable;  while  a  bloody  urine, 
with  a  black  settling,  is  pretty  certain  to  be  fatal.     Sweating, 
without  a  diminution  of  the  distressing  symptoms,  is  rarely  pro- 
ductive of  relief;  and  delirium  must  always  be  regarded  as  a 
highly  dangerous  symptom,  especially  if  it  persevere  after  the 
system  is  too  much  reduced  to  bear  general  blood-letting. 

1666.  We  have  just  said,  that  pleurisy,  like  all  the  other 
phlegmasiae,  may  terminate  in  several  ways — by  resolution  is 
the  most  common,  as  well  as  the  most  fortunate;  and  from  the 
important  discovery  of  Laennec,  as  mentioned  above,  namely, 
that  effusion  was  co-evil  with  the  inflammation,  we  are  led  to  at- 
tempt its  diminution  by  the  reduction  of  the  phlogistic  symp- 
toms ;  and  happily  this  very  often  succeeds. 

1667.  In  modern  practice,  in  this  country  especially,  where 
active  means  are  early  had  recourse  to,  we  seldom  have  oppor- 

62 


490  PLEURISY. 

tunities  of  witnessing  "  resolution"  procured  by  certain  dis- 
charges, upon  what  are  termed  the  critical  days — such  as  haemor- 
rhages from  certain  parts  of  the  body,  as  the  nose,  or  haemorrhoi- 
dal  vessels  in  men  ;  or  from  the  uterus  in  women.  By  excessive 
discharges  of  urine,  or  very  copious  expectorations,  profuse 
sweats,  or  importunate  diarrhoea.  We  think  we  have  oftener  seen 
abscesses,  critical,  than  any  other  kind  of  termination — these  may 
form  upon  almost  any  portion  of  the  body,  without  our  being 
able  to  decide  why  the  particular  part  was  selected ;  the  most 
common  however  are  the  glands  of  the  axillae,  and  parotides. 

1668.  It  may  terminate  by  suppuration,  or  rather,  agreeably 
to  Laennec,  by  a  particularly  copious  effusion,  or  "  extravasa- 
tion," from  the  whole  of  the  pleural  surface  that  is  involved  in 
the  inflammation,  as  we  have  observed  above,  par.  1645. 

1669.  This  change,  when  so  abundant  as  to  relieve  the  en- 
gorged state  of  the  vessels  of  the  pleura,  is  announced  by  symp- 
toms similarto  those  that  forerun  suppuration  properly  so  called — 
such  as  irregular  chills  in  various  parts  of  the  body,  but  espe- 
cially in  the  chest,  followed  by  evanescent  heat,  increased  diffi- 
culty in  breathing,  an  incapacity  to  dilate  the  affected  side  of  the 
chest;  the  necessity  of  lying  on  the  diseased  side;  "an  extreme 
sense  of  suffocation  upon  pressing  the  hypogastric  region."  Pinel. 
An  increase  of  size  of  the  affected  side,  with  a  separation  of  the 
ribs,  and  a  sinking  of  the  shoulder  blade;  fluctuation  between 
the  ribs,  and  a  swelling  of  the  breasts. 

1670.  Percussion  produces  a  dull  sound;  and  when  the  pa- 
tient is  shook,  a  sensation  like  water  agitated  in  a  close  vessel, 
is  perceived  by  the  patient;  and  aegophonism  by  the  stethoscope, 
when  the  patient  is  made  to  speak.    Sometimes  it  terminates  by 
the  effusion  of  blood,  and  then  becomes  the  haemorrhagic  pleu- 
risy of  Laennec.     Gangrene,  as  we  have  already  observed,  is  a 
very  rare  termination  of  this  disease. 

1671.  Pleurisy  may  be  complicated  with  the  inflammation  of 
any  of  the  thoracic  viscera,  and  it  will  then  receive  a  name  com- 
pounded of  the  parts  involved,  (par.  1543.)     We  have  already 
mentioned  the  consequences  following  the   effusion   of  serum 
within  the  cavities  of  the  thorax,  (par.  1645,  &c.) 

Jlcute  Haemorrhagic  Pleurisy. 

1672.  This  state  of  the  pleura  has  but  lately  attracted  attention — 
not  that  the  appearance  of  blood  with  effused  fluids  found  in  the 
chest  had  escaped  the  notice  of  the  pathological  anatomist,  but 
because  no  sign  was  known  that  could  point  out  this  condition 
of  the  pleura  when  its  surface  under  inflammation  was  pouring 
out  serum  and  a  greater  or  less  quantity  of  blood.  It  is  to  the 


PLEURISY.  491 

industry  of  the  modern  cultivators  of  auscultation  that  we  are 
indebted  for  a  knowledge  of  this  variety  of  pleurisy,  and  the 
mode  of  detecting  its  existence.  As  this  form  of  pleural  inflam- 
mation has  its  peculiarities,  we  have  thought  proper  to  notice  it 
with  some  of  the  other  forms  of  this  disease.  As  regards  our- 
selves, we  hesitate  not  to  confess,  we  have  never  been  sensible 
that  we  have  witnessed  the  disease  during  its  progress;  though 
we  well  remember  that  the  principal  phenomena  recorded  by 
writers,  and  especially  Laennec,  were  present  on  opening  the 
chests  of  two  who  had  died  of  thoracic  inflammation;  but  in  these 
cases,  the  blood  was  thought  to  be  an  accidental  rupture  of  a 
blood-vessel  upon  the  surface  of  the  pleura,  and  not  a  circum- 
stance of  frequent  occurrence,  and  one  more  or  less  belonging  to 
an  inflamed  condition  of  the  pleura. 

1673.  By  an  acute  hsemorrhagic  pleurisy,  Laennec  informs 
us  he  means  "  the  reunion  of  haemorrhage,  (usually  slight,)  with 
inflammation  of  the  pleura."     "  It  differs  from  the  simple  acute 
pleurisy,  not  merely  in  its  pathological  anatomy,  but  even  in  its 
progress  and  treatment."     The  phenomena  that  present  them- 
selves, are,  1.   The  effused  serum  is  tinged  with  blood.     2.  It  is 
small  in  quantity,  and  coagula  rarely  appear.     3.   Coagulable 
lymph  is  secreted  in  much  smaller  quantity  than  in  common 
pleurisy.  4.  The  false  membranes  are  thin,  and  sometimes  only 
cover  a  small  portion  of  the  pleura.     5.   "  Generally  speaking, 
in  the  haemorrhagic  the  effusion  of  fluid  is  more  abundant  than 
in  the  simple  pleurisy.     In  the  former,  also,  the  tendency  to  ab- 
sorption is  much  less,  and  the  cure  when  it  takes  place,  is  much 
more  protracted.     This  is  the  case  which  most  commonly  con- 
stitutes the  acute  empyema,"  p.  431.  6.  Instead  of  a  new  serous 
membrane  being  formed,  a  fibrous  or  fibro-cartilaginous  one  is 
produced,  which  want  the  soft  and  yielding  disposition  of  the 
serous  tissue. 

1674.  The  consequences  of  this  difference  of  product  are  se- 
verely felt  by  the  patient ;  as  by  this  arrangement  the  lung  be- 
comes bound  down  by  it  in  the  compressed  state  that  the  fluid 
effused  had  left  it,  in  the  cavity  of  the  thorax;  and  in  these  cases 
it  is  always,  as  just  noticed,  in  large  quantity,  and  remains  a  long 
time,  as  the  disposition  to  absorption  is  diminished  in  these  cases. 
But  after  a  certain  time  the  fluid  becomes  diminished  by  absorp- 
tion, but  the  lung  cannot  expand  itself  in  consequence  of  its  be- 
ing retained  in  its  position  by  the  production  of  the  fibro-carti- 
laginous texture  just  spoken  of — one  of  two  things  must  happen 
to  fill  up  the  vacancy  occasioned  by  the  removal  of  the  effused 
serum ;  either  the  ribs  will  be  drawn  inwards  so  as  to  touch  the 
lung,  or  the  part  that  was  occupied  by  the  effused  fluid,  will  be 
filled  by  an  aeriform  exhalation.     The  first  is  the  most  common, 


492  PLEURISY. 

and  constitutes  the  "  contraction  of  the  chest  consequent  to  cer- 
tain pleurisies." 

1675.  The  symptoms  of  this  species  of  pleurisy  are  not  very 
distinctly  marked ;  and  the  disease  always  requires  a  long  time 

;o  cure  itself.  The  absorption  of  fluid  requires  a  number  of 
months,  and  the  complete  contraction  of  the  chest.  After  these 
have  taken  place,  the  new  fibro-cartilaginoiis  membranes  of  the 
pleurae  come  in  contact,  and  by  the  intervention  of  a  gelatinous 
matter,  they  become  agglutinated — this  is  a  mode  of  cure  which 
nature  sometimes  adopts ;  it  however  does  not  leave  the  patient 
free  from  inconvenience,  as  a  permanent  difficulty  of  breathing 
is  apt  to  remain. 

Chronic  Pleurisy. 

1676.  This  species  of  pleurisy  is  comparatively  but  little  known 
in  this  country;  while  in  France,  and  in  other  portions  of  Eu- 
rope, it  would  appear  to  be  one  of  frequent  occurrence,  as  it  is 
described  by  a  number  of  the  continental  writers.     This  at  first 
sight  might  appear  singular;  especially  as  the  acute  form  of  this 
disease  is  one,  that  is  very  frequently  met  with.     These  facts, 
however,  are  not  beyond  explanation.     In  this  country,  the  ha- 
bits of  practice  are,  without  exception  almost,  those  of  great 
activity ;  every  acute  disease,  from  the  rapidity  with  which  it 
usually  runs  its  course,  must  be  met  with  adequate  vigour  of 
treatment,  if  success  is  to  attend  the  efforts  to  arrest  its  course — 
consequently,  pleurisy  being  a  disease  of  great  suffering,  and  one 
about  the  treatment  of  which,  there  is  less  dispute  than  almost 
any  other,  it  is  sure  to  be  met  with  adequate  depletion;  the  dis- 
ease is  therefore  properly  subdued,  or  it  proves  fatal  in  a  few 
days.     In  either  case,  the  disease  has  not  an  opportunity  to  as- 
sume a  chronic  form.     While  in  France,  and  in  other  portions 
of  Europe,  this  disease  is  of  milder  type;  which,  with  the  "  ex- 
pectant" method  of  cure  which  so  generally  prevails,  give  it  an 
opportunity  to  assume  a  lengthened  form.   But  chronic  pleurisy 
is  nevertheless  occasionally  met  with,  and  that  at  times,  in  its 
worst  forms. 

1677.  Pleurisy  may  become  chronic,  from  the  acute  form  be- 
ing changed ;  or  it  may  be  chronic,  agreeably  to  Laennec,  p.  446, 
from  its  origin. 

Anatomical  Characters. 

1678.  In  these  it  does  not  differ  essentially  from  the  acute; 
yet  the  pleura  is  of  deeper  colour,  and  the  serous  effusion  is  more 
abundant,  less  limpid,  and  much  loaded  by  albuminous  flocculi; 


PLEURISY.  493 

so  much  so,  as  sometinies  to  give  a  puriform  appearance  to  the 
effused  fluid.  It  assumes  an  intermediate  consistence  between 
the  sero-purulent  effusion  and  the  false  membrane. 

1679.  The- fluid  extravasated  in  chronic  pleurisy  is  remarka- 
ble for  the  strength  and  the  peculiarity  of  its  odour.     Laennec 
calls  it  "alliaceous;"  others  compare  it  to  phosphorated  hydro- 
gen ;  while  Professor  Nespoli,  Dr.  Forbes  informs  us,  likens  it  * 
to  asafcetida.     And  Dr.  Forbes  adds,  that  some  have  considered 
this  smell  as  declaring  a  communication  between  the  bronchia 
and  pleura ;  and  from  a  recent  case  that  we  witnessed,  this  cir- 
cumstance appeared  to  be  confirmed.    This  form  of  pleurisy  has 
but  little  disposition  to  terminate  by  resolution ;  for  in  cases  of 
extravasation  of  months  standing,  Laennec  tells  us,  that  "  no 
mark  of  any  step  towards  the  conversion  of  the  false  membranes 
Into  cellular  substance,  (par.  1655,)  could  be  observed."  p.  447. 
The  effusion  has  a  disposition  to  augment ;  the  affected  side  en- 
larges; the  intercostal  spaces  become  broader,  and  assume  a  level 
with  the  ribs,  and  sometimes  even  higher. 

1680.  The  lung  of  the  affected  side,  (par.  1639,)  becomes  re- 
duced to  a  thickness,  not  exceeding  six  lines;  and  "without  a 
careful  examination,  might  be  considered  as  entirely  destroyed.'7 
"  The  pulmonary  tissue  is  soft,  pliant,  and  dense  like  a  piece  of 
skin,  without  any  crepitation,  paler  than  natural,  grayish,  and 
almost  entirely  without  blood."  "  This  case  constitutes  the  puru- 
lent empyema."  "  It,  is  in  this  species  of  pleurisy,  that  we  must 
refer  those  histories  of  lungs  entirely  destroyed  by  suppuration." 
(par.  1640.) 

Signs  and  Symptoms. 

1681:  Laennec  declares  the  physical  signs  of  chronic  pleurisy 
to  be  the  same  as  in  the  acute,  with  the  exception  that  aegopho- 
nism  is  rarely  met  with  in  the  former,  owing  to  the  effusion  be- 
ing very  abundant  before  the  physician  is  consulted.  The  disease 
is  generally  insidious;  the  stitch,  if  it  exist,  is  slight,  and  transi- 
tory. A  fever  steals  on  by  degrees ;  the  cough  however  is  more 
frequent  than  in  the  acute  disease,  and  is  attended  by  a  mucous 
or  even  a  purulent  expectoration.  Emaciation  follows  at  a  quicker 
or  slower  pace;  the  digestive  powers  become  impaired;  the  sen- 
sibility of  the  stomach  is  sometimes  so  great,  as  not  to  bear  the 
lightest  food  or  drink.  Sometimes  so  copious  a  puriform  expec- 
toration takes  place,  as  to  give  rise  to  the  belief  that  pus  has  made 
its  way  into  the  bronchia;  this  is  observed  in  many  cases  where 
no  such  communication  exists. 

1682.  Chronic  pleurisy  is  the  purulent  empyema  of  surgeons; 
and  though  the  constitution  is  in  a  more  critical  state,  than  in  the 


404 


PLEURISY. 


acute,  yet  an  operation  bids  fair  to  succeed.  There  is  less  chance 
indeed  of  success  from  an  operation  in  the  acute,  as  the  lungs 
cannot  expand  themselves  after  it,  as  they  are  tied  down  to  the 
spine.  This  difficulty  does  not  exist  in  the  chronic  pleurisy ;  for 
there  is  either  no  false  membranes,  or  if  there  be,  they  are  soft 
and  easily  destroyed.  This  disease  is  essentially  chronic;  it 
never  presents  the  same  intensity  of  fever  or  pain  as  the  acute. 
It  only  attacks  cachectic  habits ;  and  especially  when  this  state 
proceeds  from  a  tuberculous  state  of  the  lungs.  This  form  of 
pleurisy  is  almost  always  confounded  with  phthisis. 

1683.  Laennec  has  an  interesting  chapter  on  the  contraction 
of  the  chest,  the  consequence  of  pleurisy ;  he  thinks  this  parti- 
cularly occurs  after  the  haemorrhagic  species.     This  complaint 
is  almost  new  to  the  medical  world,  but  is  now  exciting  great 
attention.     The  entire  chapter  might  be  introduced  with  profit 
to  the  reader,  did  not  its  length  prevent  our  doing  so — and  to 
be  master  of  the  subject  would  require  an  attentive  study  of  all 
its  details;  to  abridge  it,  would  be  to  render  injustice,  to  almost 
its  discoverer,  without  materially  serving  the  student.  We  there- 
fore earnestly  recommend  the  study  of  Laennec's  masterly  work 
upon  the  diseases  of  the  chest — a  work  that  leaves  every  thing 
upon  this  subject  far  behind  it.     The  reader  may  also  consult 
with  advantage  his  account  of  "latent  pleurisy." 

Of  the.  Treatment  of  Pleurisy . 

1684.  We  have  already  under  the  head  of  pneumonia  dwelt 
upon  the  mode  of  treatment  so  long,  that,  little  remains  to  be 
said  upon  the  treatment  of  acute  pleurisy ;  we  shall  therefore  re- 
fer to  what  has  been  already  proposed  for  the  reduction  of  the 
inflammation  of  the  pleura.     We  are  however  of  opinion  with 
almost  all  the  writers  upon  this  subject,  that  pleurisy  in  general 
requires  both  more  ample,  as  well  as  more  frequent  abstraction 
of  blood  than  pneumonia,  especially  by  general  bleedings. 

1685.  Leeching  and  cupping  are  most  successfully  resorted  to, 
after  the  pulse  does  not  seem  to  justify  further  depletion  from 
the  arm.     We  entirely  agree  with  Laennec,  that  cupping  is  the 
preferable  of  the  two  local  means  of  drawing  blood;  and  the  rea- 
sons he  assigns  for  the  preference  to  cupping,  altogether  coincide 
with  our  own  experience,  notwithstanding  the  high  authority  of 
Dr.  Forbes*  is  against  it.     As  this  is  a  matter  of  considerable 

*  Dr.  Forbes  in  a  note  observes,  "I  cannot  at  all  agree  with  our  author, 
(Laennec,)  in  giving1  the  preference  to  cupping  over  leeching,  in  pleurisy; 
and  I  somewhat  suspect  that,  in  this,  as  in  some  other  cases,  he  has  visited  the 
sins  of  the  advocate,"  (alluding  to  Laennec's  hostility  to  Broussais,)  "of  cer- 
tain measures  upon  the  measures  themselves.  There  are  many  obvious  reasons 


PLEURISY.  495 

practical  moment,  we  shall  employ  the  arguments  of  Laennec 
upon  this  point. 

1686.  "Leeches  are  very  often  tedious  and  painful  in  their 
action ;  sometimes  they  scarcely  fill  themselves  with  blood;  and 
at  other  times  their  punctures  will  continue  to  bleed  for  twenty- 
four  hours,  and  can  only  be  closed  by  the  cautery."*     And  he 
declares  that  he  has  even  known  fatal  bleedings  from  their  bites, 
(p.  470.)     Besides  the  objections  just  stated,  we  may  add,  that 
we  think  we  have  seen  decided  mischief  arise  from  the  exposure, 
cold,  and  wet,  that  constantly  altend  the  application  of  leeches. 
We  have  therefore  for  many  years  past  preferred  the  cupping, 
either  by  scarification  or  dry,  as  necessity  seemed  to  require. 
We  constantly  prefer  the  first,  when  the  abstraction  of  blood  is 
absolutely  required ;  and  the  latter,  when  the  emptying  of  the 
capillaries  would  answer.    When  we  have  directed  the  dry  cup- 
ping, we  have  caused  them  to  be  kept  on  until  a  slight  vesica- 
tion  would  appear — the  cups  are  then  to  be  removed.     On  this 
account  the  glass  cups  are  to  be  preferred;  but  if  these  cannot  be 
commanded,  the  others  should  be  left  on  for  forty  minutes  or 
three-quarters  of  an  hour;  the  surface  may  be  dressed  with  sim- 
ple cerate. 

1687.  In  pleurisy,  as  well  as  in  pneumonia,  it  should  be  re- 
membered, that  it  is  highly  important  to  make  a  speedy  and 
powerful  impression  upon  the  pulse — we  never  direct  the  loss  of 
blood  by  the  number  of  ounces ;  the  capacity  to  expand  the  chest, 
and  the  alleviation,  or  entire  cessation  of  pain,  is  the  only  safe 
rule,  in  such  cases.     This  abatement  of  unpleasant  symptoms 
however,  may  be  of  short  duration ;  the  symptoms  in  full  force 
may  return  in  a  short  time,  even  after  ample  depletion;  and 
especially,  after  the  first  bleeding.     In  this  case,  we  care  not  for 
the  shortness  of  the  interval  that  may  have  existed  between  the 
bleeding,  and  the  return  of  the  unpleasant  symptoms — we  in- 
stantly cause  the  loss  of  more  blood,  and  regulate  its  quantity  by 
the  same  rule.   The  many  terrible  consequences  from  the  imper- 
il think,  why  leeches  must  in  a  great  majority  of  cases  of  pleurisy,  be  prefera- 
ble to  the  application  of  cupping-glasses.     One  of  the  many  practical  advan- 
tages of  accurate  diagnosis  in  pleurisy  and  peripneumony,  is  the  much  greater 
benefit  derived  from  local  bleeding  in  the  former  than  in  the  latter  disease." 
Now  we  would  ask,  is  not  cupping  a  mode  of  local  depletion,  as  well  as  leech- 
ing, and  this  sometimes  without  some  of  the  penalties  that  attach  to  leeching? 
It  is  certainly  (cupping)  much  more  under  our  command  than  the  other,  which 
in  a  practical  view  is  sometimes  of  the  highest  consequence. 

*  We  have  found  the  application  of  punk  or  spunk,  in  every  instance  in, 
which  we  have  tried  it  for  obstinate  bleeding  from  leech  bites,  to  be  altogether 
effectual  in  arresting  it — a  piece,  or  pieces,  sufficiently  large  to  more  than 
cover  the  wound,  or  wounds,  are  to  be  applied,  and  maintained  in  their  posi- 
tion by  a  compress  and  bandage;  the  bleeding  ceases  almost  instantaneously, 
after  the  application. 


496  PLEURISY. 

feet  reduction  of  inflammation  in  pleurisy,  should  keep  us  con- 
stantly on  the  alert,  to  guard  against  them;  for  in  no  disease 
scarcely,  is  less  to  be  apprehended  from  large  losses  of  blood  than 
in  pleurisy;  and  in  none  perhaps,  are  the  benefits  from  it  more 
important  and  decided,  or  in  which,  greater  injury  may  follow 
the  neglect  of  it. 

1688.  Sydenham  was  in  the  habit  of  bleeding  freely  in  this 
disease,  and  has  left  us  his  plan  of  using  the  lancet  in  these  words. 
"  As  soon  as  I  am  called  in,  I  order  about  ten  ounces  of  blood  to 
be  drawn  from  the  arm  of  the  affected  side."     "On  the  same 
day,  (the  first  of  my  attendance,)  if  the  pain  be  very  acute,  I 
order  as  much  blood  to  be  again  taken  away;  or  else  the  next 
day;  and  if  the  pain  and  other  symptoms  rage  severely,  I  bleed 
in  this  manner  four  days  running.     But  if  the  disease  be  less 
violent  and  dangerous,  and  therefore  allows  me  to  proceed  in  a 
gentler  manner;  or  if  the  patient  be  too  weak  to  bear  repeated 
bleedings  at  such  short  intervals,  then  after  bleeding  twice,  I  in- 
terpose a  day  or  two  between  each  bleeding  afterwards.     In  this 
case  I  make  the  contraindications  my  rule;  considering  on  the 
one  hand  the  violence  of  the  disease,  and  comparing  it  with  the 
weakness  of  the  patient  on  the  other."*     He  tells  us  also,  that 
he  had  seldom  known  a  confirmed  pleurisy  subdued  by  a  less 
loss  than  forty  ounces  of  blood.     We  are  led  however  to  sup- 
pose, that  he  seldom  or  never  exceeded  ten  ounces  at  a  bleeding; 
and  hence  the  necessity  of  its  frequent  repetition — now,  we  are 
certain,  that  the  rule  we  have  laid  down  for  the  quantity  of  blood 
to  be  drawn  at  a  time  being  regulated  by  the  relief  it  is  made  to 
afford,  is  very  much  the  better  practice;  inasmuch,  as  the  relief 
is  more  immediate;  the  reduction  of  the  inflammation  more  cer- 
tain; the  course  of  the  disease  much  shortened;  and  the  con- 
valescence very  much  better  confirmed. 

1689.  After  due  depletion  from  the  circulatory  system,  pur- 
gative medicines  should  be  had  recourse  to — they  are  decidedly 
more  efficient  in  pleurisy  than  in  pneumonia;  and  this  probably 
arises  from  the  difference  in  nature  of  the  tissues  involved.    For 
purgatives  are  pretty  constantly  observed  to  be  more  useful  in 
affections  of  the  serous,  than  in  those  of  the  mucous  membranes. 
We  almost  always  commence  with  a  few  grains  of  calomel,  and 
carrying  it  off  by  magnesia,  castor  oil,  or  the  neutral  salts.     Ca- 
tharsis is  to  be  produced,  whenever  the  bowels  become  a  little 
tardy — two  or  three  evacuations  should  be  procured  daily,  dur- 
ing the  more  active  stage  of  the  disease ;  and  one  certainly  per 
diem  during  its  decline.     But  Laennec  thinks  they  are  particu- 
larly indicated  after  blood-letting,  and  when  the  symptoms  give 

*  Vol.  I.  p.  374. 


PLEURISY.  497 

rise  to  the  suspicion,  that  the  pleurisy  is  of  the  hsemorrhagic 
kind. 

1690.  Much  advantage  is  certainly  derived  from  the  exhibi- 
tion of  the  nitro-antimonial  powders — they  frequently  supersede 
the  necessity  of  giving  any  other  medicine,  for  the  double  pur- 
poses of  purging,  and  sweating.     The  nitre  however  sometimes 
disagrees  with  the  stomach;  giving  a  sensation  of  gnawing  and 
coldness — but  this  is  easily  obviated  by  the  addition  of  a  grain 
of  camphor  to  each  dose.     Should  they  operate  too  freely  upon 
the  bowels,  they  should  be  discontinued  for  a  time,  or  given  at 
longer  intervals.     (See  recipe,  page  115.) 

1691.  Blisters  are  of  great  value,  when  their  application  is 
well  timed;  and  are  as  certainly  mischievous,  when  they  are  em- 
ployed before  the  phlogistic  condition  of  the  system  is  sufficient- 
ly reduced.     We  have  already  explained  what  we  mean  by  that 
condition  of  the  system,  (which  has  been  happily,)  termed  the 
blistering  point.     (See  par.  258.)     A  blister,  to  be  as  success- 
ful as  it  may  be,  should  be  of  sufficient  dimensions,  and  be  ap- 
plied over  the  pained  part,  or  as  near  it  as  possible.     It  may  be 
suffered  to  remain  until  it  draw  amply ;  for  in  pleurisy  we  be- 
lieve, an  advantage  is  derived  from  a  large  cuticular  effusion  be- 
ing produced.     The  surface  should  be  dressed  a  few  times  with 
the  yellow  basilicon ;  the  common  dressing  with  cabbage  leaves 
should  never  be  permitted. 

1692.  Laennec  advises  the  exhibition  of  tartar  emetic  during 
the  active  stages  of  pleurisy — we  have  already  put  the  reader  in 
possession  of  his  opinions  of  this  medicine.     (See  page  467.) 
"When  the  fever  and  pain  have  ceased,"  he  observes,  "the  dis- 
ease then  enters  the  chronic  stage,  or  that  of  absorption,  which 
is  seldom  of  less  than  a  month's  duration,  and  may  sometimes 
extend  to  two  years."  p.  473.     When  an  acute  pleurisy  has  be- 
come chronic,  he  thinks  it  has  a  great  analogy  to  dropsy  ;  and  it 
is  at  this  time  he  thinks  that  blisters  applied  to  the  affected  side, 
become  very  useful;  later  in  the  disease,  he  thinks  a  seton  is  still 
better. 

1693.  It  is  of  much  importance  that  the  patient  be  well  sup- 
plied with  drinks — such  as  barley  water,  toast  water,  flaxseed 
tea,  slippery-elm  bark  tea,  or  bran  tea.     These  should  be  drunk 
cool,  and  in  liberal  quantities;  they  may  be  acidulated  by  lemon 
juice  in  a  little  currant  jelly.  No  stimulating  substance  whatever 
should  be  permitted,  be  the  pretext  what  it  may — in  a  word,  the 
most  rigid  antiphlogistic  regimen  should  be  persisted  in.     (See 
pars.  215,  216,  217.) 

1694.  Laennec  says,  that  "  during  the  first  days  of  the  disease, 
the  patient,  (unless  an  infant,)  ought  to  receive  no  food;  but 
should  be  allowed  some  liquid  aliment,  at  least,  after  three  or  four 

63 


498  PLEURISY. 

days.  This  indulgence,  (forbearance,)  is  the  surest  way  of  es- 
caping those  interminable  convalescences,  occasioned  by  the  pas- 
sage of  the  pleurisy  into  the  chronic  state."  p.  471. 

1695.  These  suggestions  are  too  loose  and  ambiguous  for  any 
valuable  practical  purpose ;  for  should  they  be  literally  followed, 
or  understood,  it  might  lead  to  great  errors  in  diet.     There  ap- 
pears to  be  a  distinction  made  between  llfood"  and  "aliment;" 
now  food  and  aliment  in  the  English  language  mean  precisely 
the  same  thing,  consequently  something  is  granted  by  way  of 
nourishment  on  the  one  hand,  that  is  ordered  to  be  withheld  on 
the  other.     Besides,  the  qualifying  term  "  liquid"  added  to  the 
word  "aliment"  seems  to  declare  that  any  nourishment  in  a 
liquid  form  would  be  eligible,  than  which  nothing  can  be  fur- 
ther from  sound  practice;  for  any  of  the  animal  jellies  can  be 
given  in  a  "  liquid"  form,  consequently  they  are  not  prohibited 
by  the  terms  of  M.  Laennec's  text.     Now,  we  believe  that  this 
gentleman  would  have  shuddered  at  the  very  idea  of  giving  any 
animal  substance  however  dilute,  in  the  acute  stage  of  pleurisy. 
Besides,  neither  vinous  nor  alcoholic  preparations  are  forbidden 
by  this  direction;  since  either  could  be  easily  added  to  any  "  fluid 
aliment"  prepared  for  the  patient,  without  infringing  on  the  di- 
rection.  We  are  therefore  of  opinion,  that  the  directions  respect- 
ing the  food  of  the  patient,  was  a  slip  of  the  author's  pen  ;  while 
we  think  that  a  little  blame  should  attach  to  his  very  able  and 
learned  translator,  for  allowing  these  rules  to  pass  unchallenged. 

1696.  We  are  equally  surprised  that  an  exception  should  be 
made  in  favour  of  an  "  infant ;"  for  as  far  as  our  experience  goes, 
we  have  ever  found  it  necessary  to  be  as  rigourous  in  diet  with 
children  as  with  adults.     If  they  are  at  the  breast,  we  do  not  per- 
mit them  to  be  nursed  but  at  long  intervals,  and  then  only  in 
small  quantities,  and  at  the  same  time  to  put  the  nurse,  be  she 
the  mother,  or  a  hireling,  upon  an  abstemious,  vegetable  diet. 
Indeed,  we  are  of  opinion,  that  children  bear  these  privations 
even  better  than  more  aged  persons — but  be  this  as  it  may,  we 
are  sure  they  require  the  abstraction  of  nourishment  of  every 
kind,  as  certainly  as  the  adult,  and  to  as  great  an  extent.* 

1697.  We  therefore  under  these  impressions,  never  permit  a 
pleuritic  patient,  be  he  young  or  old,  to  have  any  other  food  dur- 
ing the  active  stage  of  the  disease,  than  the  thin  vegetable  jellies 
named  above;  that  is,  the  linseed  tea,  barley  water,  &c.  (par.  214,) 
these  serving  the  double  purposes  of  drink  and  nourishment. 

1698.  Sydenham  speaks  highly  of  the  practice  of  allowing  the 

*  "As  to  diet,  I  forbid  all  flesh-meats  and  the  smallest  flesh-broths,  and  ad- 
vise the  patient  to  sup  barley  broth,  water  gruel,  and  panada;  and  to  drink 
ptisan  made  of  pearl  barley,  sorrel,  and  liquorice  roots,  &c.  boiled  in  water." 
— Sydenham,  Vol.  I.  p.  374. 


PHTHISIS    PULMONALIS,    OR    CONSUMPTION.  499 

patient  to  sit  up;  he  says,  "  to  prevent  the  patient's  being  over- 
heated during  the  continuance  of  the  distemper,  I  allow  him  to 
sit  up  a  few  hours  every  day,  as  his  strength  will  permit;  which 
indeed  is  of  such  moment  here,  that  if  he  be  kept  always  in 
bed,  neither  the  plentiful  evacuations  of  blood,  nor  the  most 
cooling  remedies,  will  sometimes  at  all  avail  in  conquering  the 
symptoms."  Vol.  I.  p.  376. 

1699.  Laennec  is  also  an  advocate  for  this  plan ;  he  says,  "it 
has  frequently  appeared  to  me  to  have  contributed  powerfully 
towards  subduing  the  inflammation."  p.  471. 

1700.  The  plan  laid  down  for  the  treatment  of  pleurisy,  will 
for  the  most  part  be  sufficient  for  its  removal;  yet  occasionally  it 
proves  fatal  under  the  best  devised  plan,  and  the  most  vigorous 
and  best  adapted  treatment.     While,  on  the  other  hand,  we  are 
told  by  Laennec,  that,  "  in  this,  as  in  most  acute  diseases,  the 
unaided  resources  of  nature  are  very  great;  and  that  a  great  num- 
ber of  pleurisies,  if  left  entirely  to  themselves,  would  do  well. 
This  much  is  certain,  that  a  cure  frequently  takes  place  when 
the  treatment  amounts  almost  to  nothing,  or  even  when  it  is 
conducted  on  principles  opposed  both  by  reason  and  experience. 
It  is  even  now  by  no  means  uncommon,  particularly  in  country 
places,  to  meet  with  persons  who  attempt  the  cure  of  pleurisy 
according  to  the  sudorific  plan  of  Paracelsus  and  Van  Helmont; 
that  is,  with  hot  wine  or  brandy,  and  aromatics,  such  as  pepper, 
ginger,  cinnamon,  and  juniper,  or  coriander  berries;  the  dung  of 
horses  or  sheep  infused  in  wine,  &c.     And  yet  all  the  patients 
of  these  sages  do  not  die:  a  salutary  crisis  occasionally  triumphs 
over  both  the  disease  and  the  treatment."  p.  473. 

SECT.  VIII. — PHTHISIS  PULMONALIS,  OR  CONSUMPTION. 

1701.  In  a  work,  professing  to  be  practical,  it  becomes  as 
much  a  duty  to  treat  of  the  diseases  which  common  experience 
and  consent  declare  to  be  generally  incurable,  as  of  those,  that 
are  strictly  amenable  to  medical  discipline,  or  directions.     We 
therefore  feel  it  is  right  to  speak  of  the  common,  and  truly  for- 
midable disease,  phthisis,  though  we  are  obliged  at  once  to  con- 
fess, it  almost  always  baffles  the  best  concerted  means  we  can 
employ.  Though  this  is  strictly  true,  yet  with  even  our  limited 
acquaintance  of  its  absolute  nature,  we  have  it  very  constantly 
in  our  power  to  mitigate  the  violence  of  its  symptoms,  to  dimi- 
nish the  sufferings  consequent  upon  its  progress,  and,  in  some 
instances,  even  to  retard  its  fatal  termination,  or  effect  a  cure. 

1702.  If  this  be  true,  we  have  strong  inducements  to  investi- 
gate its  nature,  by  studying  its  etiology  and  pathology;  ascertain- 
ing its  peculiarities;  detailing  its  symptoms;  discriminating  its  va- 


500  PHTHISIS    PULMONALIS,    OR   CONSUMPTION. 

rieties;  determining  its  location  and  extent;  and  endeavouring  to 
lay  down  the  best  plan  of  treatment  that  our  present  limited  know- 
ledge of  some  of  the  great  points  just  named,  will  permit  us  to  do. 

1703.  It  has  been  asked  by  Broussais,*  Laennec,t  and  others, 
is  phthisis  a  cut-able  disease?  this,  with  certain  strict  limitations, 
has  been  answered  in  the  affirmative  by  both  the  gentlemen 
just  named ;  and  others  have  declared,  that  their  practice  has  af- 
forded a  number  of  successful  cases.     The  first  named,  thinks, 
that  phthisis  may  be  cured,  when  there  is  but  one  or  two  tuber- 
cles, and  when  these  have  softened,  and  been  expectorated ;  as 
the  tubercular  cavities  may  then  cicatrize,  and  the  patient  be 
cured.     Here  indeed  is  but  a  very  limited  condition  to  rest  the 
hope  of  cure   upon;  especially,  as  we  must  all  believe,  with 
Broussais  himself,  that  the  cause  which  gave  rise  to  one  or  two 
tubercles,  may  operate  to  produce  a  very  much  more  abundant 
crop,  though  these  may  be  in  slow  succession.  He  appears,  how- 
ever, to  admit  the  possibility  of  cure  in  his  Exam,  des  Doct. 
Med.  upon  a  more  extensive  scale,  than  he  does  in  his  Phlegm. 
Chron. 

1704.  Indeed,  cures  would  be  rendered  very  probable,  were 
his  hypothesis  of  the  cause  of  tubercles  true;   namely,  that  they 
are  the  product  of  inflammation,  however  excited  in  the  pulmo- 
nary tissue.     Were  this  so,  it  might  perhaps  often  happen,  that 
the  disease  could  be  arrested,  and  even  cured,  by  taking  the  dis- 
ease in  its  forming  state,  or  even  in  its  first  stage.    But  unfortu- 
nately, the  basis  of  this  expectation  is  not  well  founded,  as  we 
shall  have  occasion  to  say  presently;  consequently,  the  mode  of 
treatment  predicated  upon  it,  cannot  be  successful. 

1705.  As  regards  such,  who  have  declared  their  belief,  (ho- 
nestly, without  doubt,)  that  they  had  cured  consumption,  we 
must  believe  they  were  almost  always  in  error;  as  these  declara- 
tions have  come  from  those,  who  had  very  partially  investigated 
the  pathology  of  the  disease,  or  perhaps  not  at  all;  and  who,  con- 
sequently, were  almost  altogether  ignorant  of  the  nature  of  tu- 
bercles, and  not  in  possession  of  the  signs  that  discriminate  chro- 
nic catarrh  from  a  true  phthisis. 

1706.  On  this  point  LaennecJ  very  justly  observes,  "  to  many 
practical  physicians,  who  are  not  anatomists,  the  possibility  of  a 
cure  taking  place  after  the  formation  of  an  ulcerous  excavation 
of  the   lungs,  may  seem  quite  admissible.     This  opinion,  how- 
ever, will   in  all  likelihood   appear  quite  absurd  to  those  who 
have  paid  much  attention  to  morbid  dissection.     Previously  to 
the  knowledge  of  the  true  character  and  mode  of  development 

*  Phlegm.  Chron.  Vol.  II.  p.  151. 

f  Diseases  of  the  Chest,  Forbes'  Translation,  p.  299.  *  Ibid. 


PHTHISIS   PULMONALIS,    OR    CONSUMPTION.  501 

of  tubercles,  and  while  consumption  was  considered  simply  as  a 
consequence  of  the  chronic  inflammation,  and  slow  suppuration 
of  the  pulmonary  tissue,  medical  men  did  not  question,  any 
more  than  the  vulgar  do  now,  the  possibility  of  curing  this  dis- 
ease by  a  suitable  mode  of  treatment,  especially  if  taken  in  time, 
and  during  ihejirst  stage  of  it.  It  is  now,  however,  the  gene- 
ral opinion  of  all  those  who  are  acquainted  with  the  actual  state 
of  our  knowledge  respecting  the  pathology  of  diseases,  that  the 
tubercular  affection,  like  cancer,  is  absolutely  incurable,  inas- 
much as  nature's  efforts  towards  effecting  a  cure  are  injurious, 
and  those  of  art  are  useless."  "  Crude  tubercles  tend  essentially 
to  increase  in  size,  and  to  become  soft.  Nature  and  art  may  re- 
tard, or  even  arrest  their  progress  ;  but  neither  can  reverse  it. 
But  while  I  admit  the  incurability  of  consumption  in  the  early 
stages,  I  am  convinced  from  a  number  of  facts,  that  in  some 
cases  the  disease  is  curable  in  the  latter  stages;  that  is,  after  the 
softening  of  the  tubercles,  and  the  formation  of  the  ulcerous  ex- 
cavation." 

1707.  So  far  Broussais  and  Laennec  agree,  with  this  excep- 
tion, however,  that  the  former  has  limited  within  a  much  nar- 
rower compass  the  condition  of  the  lung  necessary  to  a  cure, 
than  the  latter.  It  would  not  appear  essential  to  the  cure  of  con- 
sumption, that  the  tubercles  should  be  so  few  as  stated  by  Brous- 
sais; since,  if  all  that  exist  in  the  lungs  should  soften  down,  and 
be  expectorated  at  the  same  time,  the  chance  of  recovery  might 
be  equal.    But  unfortunately,  the  history  of  these  bodies  furnish 
us  with  but  slender  expectations  that  this  either  has,  or  will  take 
place  frequently.     Indeed,  it  seems  to  be  a  point  on  which  all 
the  late  pathologists  agree,  that  there  are  successive  crops  of 
these  bodies  in  the  lungs;  and  that  no  sooner  has  one  set  run  on 
to  suppuration,  than  another  succeeds  until  life  is  extinguished. 
At  other  times,  tubercles  are  observed  to  be  in  all  the  various 
stages  of  their  existence,  in  the  same  lungs,  at  one  and  the  same 
time. 

1708.  Thus,  miliary  tubercles,  some  of  larger  size,  but  yet 
solid;  those  that  were  softening ;  others  softened;  many  suppu- 
rate; and  ulcerous  excavations,  betraying  either  the  recent,  or 
long  evacuation  of  their  pus,  have  been  found  at  one  and  the 
same  time,  in  the  same  individual.     Now,  it  would  appear  from 
the  researches  of  Broussais,  Laennec,  Bayle,  &c.  that  this  is  the 
almost  constant  progress  and  termination  of  tubercles  that  do  not 
run  their  course  with  great  rapidity;  for  in  this  there  is  a  very 
great  variety  depending  principally  upon  the  force  of  the  excit- 
ing cause;  the  susceptibility  of  the  system ;  and  the  opposition 
to  their  development,  from  dietetic  observances,  medical  disci- 
pline, &c.     This  being  true,  we  see  that  consumption,  though 


502  PHTHISIS    PULMONALIS,    OR    CONSUMPTION. 

not  an  absolutely  incurable  disease,  yet  is  one  in  which  the  co- 
incidences, essential  to  success,  can  very  rarely  combine.  These 
facts,  however,  should  teach  the  practitioner  reserve  in  his  prog- 
nostic, and  still  more  in  inspiring  confidence,  where  nothing  can 
be  hoped  for. 

1709.  Laennec  has  related  a  most  interesting  case,  among  se- 
veral others,  in  which  every  thing  was  to  be  dreaded,  but  in 
which  an  entire  cure  was  effected.     As  this  case  cannot  fail  to 
interest,  we  shall  relate  it  at  length,  especially  as  the  work  from 
which  it  is  derived,  is  in  the  hands  of  but  few  in  this  country, 
though  its  merits  claim  it  should  be  possessed  by  every  practi- 
tioner. 

1710.  "  Tuberculous  Phthisis  cured. — An  English  gentle- 
man, aged  thirty-six,  detained  at  Paris  as  a  prisoner  of  war,  in 
September,  1813,  had  an  attack  of  haemoptysis,  followed  by  a. 
cough,  at  first  dry,  but  in  the  course  of  a  few  weeks  accompa- 
nied by  purulent  sputa.   To  these  symptoms  were  added  a  well- 
marked  hectic,  considerable  dyspnoea,  copious  night  sweats,  ema- 
ciation, and  great  debility.  The  chest  sounded  well  every  where 
except  under  the  right  clavicle,  and  in  the  axilla  of  the  same 
side.   The  haemoptysis  returned  in  a  slight  degree,  now  and  then, 
and  in  December  he  had  diarrhoea,  which  was  with  difficulty 
checked  by  .astringents.    In  the  beginning  of  January  he  was  so 
much  reduced,  that  both  MM.  Halle  and  Bayle  agreed  with  me  in 
opinion  that  his  death  might  be  daily  looked  for.     On  the  15th 
of  January,  during  a  severe  fit  of  coughing,  and  after  bringing 
up  some  blood,  he  expectorated  a  solid  mass,  of  the  size  of  a  fil- 
bert, which  upon  examination,  I  found  to  be  evidently  a  tuber- 
cle in  the  second  stage,  surrounded  apparently  by  a  portion  of 
the  pulmonary  tissue.  This  patient  remained  in  the  same  degree 
of  extreme  emaciation  and  debility  all  January,  being  expected 
to  die  daily;  but  in  the  beginning  of  February,  the  perspiration 
and  diarrhoea  ceased  spontaneously,  the  expectoration  sensibly 
diminishing,  and  the  pulse,  which  had  been  constantly  as  high  as 
120,  fell  to  90.    In  a  few  days  the  appetite  returned,  the  patient 
began  to  move  about  in  his  room,  his  emaciation  became  less,  and 
against  the  end  of  the  month,  his  convalescence  was  evident.  In 
the  beginning  of  April  he  was  perfectly  recovered,  and  his  health 
has  continued  good  ever  since,  without  even  the  least  cough, 
and  without  his  being  at  all  guarded  in  his  climate  or  regimen. 
In  1818  this  patient  consulted  me  for  a  different  complaint,  and  I 
took  the  opportunity  of  examining  his  chest  by  means  of  the 
stethoscope.     The  only  thing  I  could  detect,  was  the  compara- 
tive indistinctness  of  respiration  in  the  superior  portion  of  the 
right  lung,  as  low  as  the  third  rib.  This  part,  however,  sounded 
as  well  on  percussion  as  the  opposite  side,  and  there  was  no  pec- 


PHTHISIS    PULMONALIS,    OR    CONSUMPTION.  503 

toriloquism.  From  these  circumstances  I  am  of  opinion,  that  the 
excavation  which  contained  the  expectorated  tubercle  must  have 
been  replaced  by  cellular  or  fibro-cartilaginous  cicatrice;  and  as 
the  total  absence  of  cough,  dyspnoea,  and  expectoration  for  so 
long  a  period,  forbids  the  supposition  of  the  existence  of  others 
in  the  lungs,  I  think  we  have  a  right  to  consider  this  patient  as 
perfectly  cured.  In  1824,  this  gentleman  was  examined  at  Rome 
by  Dr.  Clark,  an  English  physician,  who  practises  there  with 
great  distinction,  and  who  recognised  him  as  the  subject  of  the 
case  just  detailed.  I  saw  him  also  the  same  year,  and  found 
him  precisely  in  the  same  state  as  in  1818."  To  this  account, 
Dr.  Forbes  adds,  "  I  learn  from  Dr.  Clark,  who  is  now  resident 
in  London,  that  Mr.  G.  is  still  living,  and  in  good  health.  Se- 
veral well-marked  instances  of  expectorated  tubercles  are  upon 
record.  A  very  remarkable  case  is  recorded  in  the  Journal  de 
Med.  torn.  78,  for  March,  1789.  In  this  case  the  patient  also 
recovered,  though  previously  on  the  brink  of  the  grave."  p.  320. 

1711.  Bayle's*  fifty-fourth  case  is  also  an  instance  of  con- 
sumption being  cured,  but  not  by  the  expectoration  of  tubercles. 
It  was  thought  by  both  Bayle  and  Laennec  to  be  a  case  of  chro- 
nic catarrh,  as  neither  at  the  time  considered  it  possible  to  cure 
consumption.  Bayle,  in  his  work,  makes  no  particular  observa- 
tions upon  the  case;  but  Laennec  says,  that  some  time  after,  he 
had  an  opportunity  to  satisfy  himself  of  the  nature  of  the  disease 
by  the  cylinder,  and  declares,  "  that  our  patient  had  more  than 
a  mere  catarrh.     His  respiration  is  quite  perfect  throughout  the 
whole  chest,  except  at  the  top  of  the  right  lung,  in  which  point 
it  is  entirely  wanting.     On  this  account  I  am  certain  that  this 
portion  of  the  lung  had  been  the  seat  of  an  ulcerous  excavation, 
and  that  this  has  been  replaced  by  a  complete  and  solid  cica- 
trice." p.  322. 

1712.  Laennec,  p.  323,  concludes  his  interesting  observations 
by  the  following  important  remarks.  "  To  conclude,  I  think  that 
the  cure  of  consumption,  where  the  lungs  are  not  completely 
disorganized,  ought  not  to  be  looked  upon  as  at  all  impossible, 
in  reference  either  to  the  nature  of  the  disease  or  of  the  organ 
affected.     The  pulmonary  tubercles  differ  in  no  respect  from 
those  found  in  scrofulous  glands  ^  and  we  know  that  the  soften- 
ing of  these  latter  is  frequently  followed  by  a  complete  cure. 
On  the  other  hand,  the  destruction  of  a  part  of  the  substance  of 
the  lungs  is  by  no  means  necessarily  mortal,  since  we  know 
that  even  wounds  of  these  organs  are  frequently  cured,  notwith- 
standing the  unfavourable  conditions  with  which  they  are  neces- 

*  Researches,  p.  454. 


504  PHTHISIS   PULMONALIS,    OR    CONSUMPTION. 

sarily  complicated,  by  the  perforation  of  the  walls  of  the  chest, 
and  the  admission  of  air  into  the  pleura." 

1713.  These  cases,  with  their  accompany  ing  observations,  de- 
serve the  serious  consideration  of  the  medical  practitioner;  for 
they  encourage  a  hope,  in  cases  of  the  most  desperate  character, 
that  by  a  kind,  persevering,  and  a  well-adapted  plan  of  proceed- 
ing, we  may  be  rewarded  with  success.     They  will  tend  to  ba- 
nish that  indifference  towards  the  suffering  many,  that  the  gene- 
ral hopelessness  of  their  situation  but  too  constantly  produces; 
and  will  prevent  that  recklessness  to  whatever  the  patient  may 
do,  either  as  regards  diet,  or  the  perseverance  in  a  well-directed 
medical  course.     May  not  many  have  fallen  victims  to  this  su- 
pineness  on  the  part  of  the  medical  attendant?   May  not  the  too 
often  granted  indulgence  of  a  wayward  appetite,  and  the  entire 
neglect  of  all  the  Hygiean  means,  have  proved  fatal  in   cases, 
where  the  disease  was  not  necessarily  mortal?    Do  they  not  re- 
concile us  to  exertions,  that  are  too  often  looked  upon  as  ill-be- 
stowed, because  they  are  so  seldom  successful?     Do  they  not 
prove,  that  consumption,  so  far,  is  a  more  curable  disease  than 
cancer,  hydrophobia,  or  perhaps  even  traumatic  tetanus  ?     Yet 
in  either  of  these  diseases,  who  thinks  of  abandoning  the  pa- 
tient, because  hitherto  cures  have  rarely,  if  ever,  been  effected? 
But  at  the  same  time,  let  us  repeat,  that  these  considerations 
should  not  make  us  hold  out  with  too  much  facility,  a  hope  that 
can  be  but  extremely  rarely  realized. 

1714.  Were  we  to  rely  implicitly  upon  the  bills  of  mortality, 
we  should  be  awfully  impressed  with  the  ravages  of  "  consump- 
tion."   But  we  must  not  take  for  granted,  that  the  calculations 
upon  this  point  are  correct ;  for  there  are  several  sources  from 
which  errors  may  arise — 1.   From  every  chronic  affection  with 
great  emaciation,  if  attended  with  cough,  though  there  may  be 
no  purulent  expectoration  or  hectic  fever,  being  called  "  con- 
sumption." 2.  From  every  protracted  case  of  disease  with  ema- 
ciation attended  by  hectic  fever  being  classed  as  consumption, 
though  some  other  viscera  than  the  lungs  may  have  been  the 
seat  of  the  disease  and  the  cause  of  death.   3.  From  every  chro- 
nic cough  being  looked  upon  as  "  consumption,"  though  the 
disease  may  have  been   chronic  pneumony,  catarrh,  or  pleu- 
risy, &c. 

1715.  With  so  much  room  for  inaccuracy,  it  is  very  presuma- 
ble that  much  error  prevails  upon  this  subject — thus,  we  are  in- 
formed, that  the  deaths  from  this  disease  in  England  amount  to 
no  less  than  fifty-five  thousand  ;  and  that  in  London  it  causes 
one-fourth  of  the  deaths.     The  same  observations  we  have  no 
doubt  will  apply  to  every  place  in  which  bills  of  mortality  are 


PHTHISIS    PULMONALIS,    OR    CONSUMPTION.  505 

kept.  Error  must  ever  prevail,  where  certainty  cannot  be  ar- 
rived at,  as  regards  the  essential  nature  of  the  disease  of  which 
a  patient  may  have  died — for  there  is  but  one  method  of  ascer- 
taining this;  namely,  by  post  mortem  examinations.  Against 
this  test  unfortunately,  many  causes  operate,  and  will,  we  fear, 
too  long  continue  to  do  so. 

1716.  1.  Prejudice  against  the  practice,  arising  from  supersti- 
tious apprehension,  or  from  a  horror  in  having  the  body  of  the 
deceased  disturbed.     2.  From  an  indifference  to  such  examina- 
tions, and  this  of  the  most  reprehensible  kind,  on  the  part  of  the 
practitioner,  since  he  loses  by  it  important  information.    3.  In- 
competency  to  perform  the  operation,  owing  to  a  defect  in  ele- 
mentary studies,  thereby  being  disqualified  to  judge  between  a 
healthy  and  a  diseased  structure;  or  perhaps  incapable  of  naming 
the  deranged  part,  or  of  declaring  in  what  the  aberrations  con- 
sist. 

1717.  From  the^operation  of  these  causes,  there  must  neces- 
sarily result  much  uncertainty  as  regards  the  essential  nature  of 
the  disease  of  which  the  patient  died;  and  consequently,  the 
artificial  character,  or  the  character  drawn  from  symptoms,  is 
very  constantly  substituted  for  it.     Yet  with  all  the  allowances 
that  can  be  made  for  error,  we  are  persuaded  that  a  very  large 
proportion  of  the  human  race  is  carried  off  by  this  insidious  and 
formidable  disease.  For  all  climates  are  subject  to  it,  though  not 
in  an  equal  degree;  thus  the  more  northern  and  temperate  cli- 
mates are  more  obnoxious  to  phthisis,  than  the  hot  countries; 
and  position  is  also  supposed  to  exert  an  influence,  independently 
of  temperature.     Thus,  "  in  large  cities  it  is  more  frequent  than 
in  small  ones ;  and  more  frequent  in  the  latter  than  in  the  coun- 
try."   Laennec  is  of  opinion  that  it  is  less  frequent  in  maritime 
situations,  than  in  the  interior  of  the  country      Dr.  Forbes  does 
not  agree  with  this  respectable  authority  on  this  point,   and 
places  the  experience  of  Blane,  Trotter,  Johnson,  Burnett,  &c. 
in  opposition  to  it. 

1718.  From  what  has  been  said,  it  will  appear  incumbent  on 
us  to  define  what  condition  of  the  lungs  should  be  considered  as 
essentially  constituting  "consumption."     To  fix  this  we  shall 
not  have  recourse  to  any  but  the  very  modern  pathologists,  since 
they  alone  have  ascertained  the  departures  from  healthy  struc- 
ture, and  agreed  upon  what  should  constitute  phthisis. 

1719.  Mr.  Bayle  says,   "the  generic  character  of  phthisis 
may  be  drawn  from  the  symptoms,  or  from  the  nature  and  seat 
of  the  disorder ;  that  is  to  say,  it  may  be  either  artificial  or  es- 
sential.    But  it  appears  to  me  indispensable  to  unite  these  two 
characters.     The  artificial,  which  is  drawn  from  the  symptoms, 
is  not  applicable  either  to  all  degrees  or  to  all  cases  of  phthisis. 

64 


506  PHTHISIS    PULMONALI3,    OR    CONSUMPTION. 

The  essential  character,  which  expresses  the  nature  and  seat  of 
the  disorder,  suits  it  in  every  degree  and  every  form  it  can  take, 
but  would  be  insufficient  to  know  it  by  during  life.  As  it  re- 
sults from  my  researches,  the  essential  character  of  phthisis  is 
this:"— 

1720.  "Every  injury  of  the  kings,  which  left  to  itself  pro- 
duces a  progressive  disorganization  of  them,  and  in  the  end  ul- 
ceration  and  death,  ought  to  be  called  pulmonary  phthisis." 

1721.  This  definition  would  have  been  more  perfect  had  not 
"death"  been  considered  essential  to  its  character;  for  we  have 
just  seen  that  death  does  not  always  follow,  even  in  the  best 
ascertained  cases  of  consumptions     Nor  is  ulceration  a  constant 
condition  of  the  parenchyma  of  the  lungs,  though  death  may 
take  place.  Broussais*  gives  a  remarkable  case  of  this  kind  ;  in- 
deed there  was  an  absence  of  all  the  usual  symptoms  of  phthisis 
except  cough ;  that  is,  there  were  neither  hectic  fever,  diarrhoea, 
night  sweats,  nor  purulent  expectoration,  though  there  were 
tubercles  to  a  very  large  amount;  indeed  he  says,  "they  formed 
three-fourths  of  the  whole  bulk  of  the  left  lung."  Some  of  these 
"equalled  a  hen's  egg  in  size,  and  consisted  of  dry  cheesy  mat- 
ter, which  was  very  easily  broken."     Drs.  Physick,  Otto,  and 
myself,  attended  a  young  lady  of  this  city,  in  the  course  of  the 
disease  which  destroyed  her,  there  was  not  a  single  symptom 
that  betrayed  there  was  the  slightest  mischief  lurking  in  the 
lungs — there  was  neither  cough,  difficulty  of  breathing,  hectic 
fever,  nor  purulent  expectoration,  which  Pinel  makes  constitute 
phthisis;  there  was  marasmus,  but  it  was  not  excessive.     On 
opening  the  body,  the  lungs  alone  were  found  diseased.    In  an- 
other instance,  Dr.  Chapman  and  myself  attended  a  boy  of  eight 
or  nine  years  old,  whose  disease  appeared  to  be  located  in  the 
abdomen — in  this  part,  he  appeared  to  suffer  excruciating  agony, 
which  powerful  doses  of  laudanum  would  scarcely  abate ;  and 
this  continued  to  the  last  moment  of  his  existence,  t 

1722.  On  opening  the  body,  none  of  the  abdominal  viscera 
were  at  all  diseased;  the  lungs  alone  were  the  seats  of  the  disor- 
der.   They  contained  very  large  quantities  of  the  most  offensive 
pus  I  ever  remember  to  have  encountered  ;  yet  in  this  case  there 
was  not  a  solitary  symptom  to  direct  attention  to  the  chest. 
Bayle  has  therefore  said  correctly,  that  the  "  artificial  character 
of  phthisis"  is  not  applicable  to  all  its  degrees,  or  to  all  cases. 
And  that  the  "  essential"  "  would  not  be  sufficient  to  know  it  by 
during  life."     In  fact,  we  have  no  pathognomonic  symptom  of 

•  Phleg.  Chron.  Vol.  II.  p.  194. 

f  Indeed  we  may  look  upon  Bayle's  38th  and  39th  cases  as  being  cases  with- 
out the  patl.ognomonic  signs  of  phthisis. 


PHTHISIS    PULMONALIS,    OR    CONSUMPTION.  507 

phthisis — the  knife  alone  reveals  its  existence  with  absolute  cer- 
tainty.* 

Causes  of  Phthisis. 

1723.  Laennec  says,  that  "the  progress  of  pathological  ana- 
tomy has  successfully  demonstrated  that  phthisis  pulmonalis  is 
owing  to  the  development  in  the  lungs  of  a  particular  species  of 
accidental  production^  to  which  modern  anatomists  have  re- 
stricted the  name  of  tubercle"  "This,  I  think,  is  the  only  kind 
of  phthisis  which  we  should  admit,  unless  indeed  it  were  the 
phthisis  nervosa,  and  the  chronic  catarrh  simulating  tuberculous 
phthisis."  p.  271. 

'utr.cft'^-Ijtb  v.-.siju-h:»ijwi  viJ';'j*iiui  «m  i;i>:  ^!sa«»? 
Mode  of  Development. 

•    '<  ./:r-fctvj"«}j77v..  ;;.' tad:  *c 

1724.  We  are  informed  by  the  same  authority  that  tubercles 
may  develope  themselves,  as  insulated  bodies,  or  in  interstitial 
injection  or  infiltration.     The  first  may  show  themselves  under 
several  forms,  to  which  he  has  given  the  names  of  miliary,  crude, 
granular,  and  encysted.    The  second  presents  three  varieties,  as 
the  irregular,  the  gray,  and  the  yellow.     But  in  whatever  form 
the  tuberculous  product  developes  itself  eventually,  it  always  at 
first  is  of  a  gray,  semitransparent  appearance,  which  gradually 
becomes  yellow,  opaque,  and  very  dense.     When  it  softens,  it 
acquires  a  fluidity  equal  to  that  of  pus;  and  when  expelled  from 
the  lungs,  it  leaves  what  is  commonly  called  ulcers  of  the  lungs, 
but  which  Laennec  denominates  tuberculous  excavations.  The 
following  are  the  descriptions  of  these  varieties. 

1.    The  Miliary  Tubercles. 

1725.  This  is  the  most  common  form  of  tubercles  in  the  lungs. 
They  resemble  small  grains,  are  of  a  semitransparent  gray  colour, 
and  sometimes  have  a  consistency  almost  equal  to  cartilage.  They 
differ  in  size  from  a  millet  to  a  hemp-seed.  They  are  intimately 
connected  with  the  pulmonary  substance;  so  much  so,  that  they 
cannot  be  removed  without  bringing  with  them  a  portion  of  it. 
They  become  united  in  groupes.  Before  this  takes  place,  a  sinall 

*  We  might  with  much  safety,  include  the  stethoscope;  but  as  this  instru- 
ment is  so  little  understood  in  this  country,  and  employed  so  rarely,  that  we 
hardly  dare  at  this  time  consider  it  as  a  discriminating  means,  though  it  is  ab- 
solutely one  of  great  certainty. 

f  "  Under  the  term  accidental  productions,  I  comprehend  every  substance 
foreign  to  the  natural  organization  of  a  part,  which  any  aberration  in  the  nutri- 
tion may  develope  in  our  organs."  p.  271. 


508  PHTHISIS    PULMONALIS,    OR   CONSUMPTION. 

yellowish  speck  appears  in  the  centre  of  each  tubercle,  which 
eventually  involves  the  whole  tubercle.  After  a  while,  the  whole 
mass  is  converted  into  a  single  homogeneous  body  of  a  whitish- 
yellow  colour,  and  nearly  as  dense  as  cartilage — it  now  consti- 
tutes the  yellow  crude  tubercle,  or  simply  the  crude  tubercle. 
When  the  tubercle  preserves  its  original  roundish  form,  it  is 
thought  to  originate  from  a  single  point  or  granule. 

2.  Granular  Tubercles,  or  Miliary  Granulations. 

1726.  This  variety  is  said  to  be  rare,  and  was  first  described 
by  Bayle ;  and  from  its  peculiar  character  was  thought  by  him 
to  be  an  accidental  production.     These  are  nearly  of  the  size  of 
millet  seed,  and  are  perfectly  round — they  differ  from  other  tu- 
bercles in  being  uniform  in  size,  transparent  and  colourless. 
Laennec  thinks  Bayle  was  mistaken  in  looking  upon  these  bodies 
as  different  from  tubercles,  and  still  more  in  regarding  them  as 
accidental  cartilages. 

3.    Gray  Tuberculous  Infiltration. 

1727.  This  infiltration  is  frequently  found  around  tuberculous 
excavations.    They  sometimes  exist  primitively,  without  tuber- 
cles ;  this  is  rare.     At  other  times  there  are  large  tuberculous 
masses  in  the  first  stage,  without  miliary  tubercles.  These  masses 
are  dense,  humid,  and  impermeable  to  air — upon  cutting  them 
they  are  found  nearly  as  dense  as  cartilage,  and  the  vesicular 
structure  of  the  lungs  is  altogether  lost.     As  these  advance  to 
softening,  small  yellow,  opaque  specks  show  themselves ;  these 
increase  in  size,  and  eventually  involve  the  whole  mass,  and 
convert  it  into  yellow  tuberculous  matter. 

4.  Jelly-like  Tuberculous  Infiltration. 

1728.  In  the  intervals  of  the  miliary  tubercles,  a  small  infil- 
tration of  matter,  rather  humid  than  fluid,  is  frequently  found. 
It  is  colourless,  or  very  slightly  tinged  with  blood,  and  resem- 
bles a  fine  jelly.     This  acquires  consistence,  and  is  eventually 
converted  into  the  tuberculous  matter  just  described.     These 
masses  are  produced  by  infiltration  into  the  pulmonary  tissue, 
while  the  common  round  tubercles  are  foreign  bodies,  which 
press  aside  and  separate  the  substance  of  the  viscus  on  all  sides, 
rather  than  penetrate  into  its  parenchyma.     These  masses  may 
occupy,  occasionally,  a  considerable  part  of  one  lobe,  without 
altering  in  any  way  its  shape. 


PHTHISIS   PULMONALIS,  OR    CONSUMPTION.  509 


Progress. 

1729.  But  "  in  whatever  manner  the  crude  tubercles  are  fo  .  Hi- 
ed, after  a  very  variable  period,  they  finally  become  soft  and 
fluid.    The  process  begins  in  the  centre  of  each  mass,  and  gradu- 
ally increases,  the  tuberculous  matter  becoming  daily  softer  and 
moister,  cheesy,  or  at  least   unctuous  to  the  touch,  like  soft 
cheese,  and  finally  acquires  the  viscidity  and  fluidity  of  pus. 
The  softening  gradually  attains  the  surface,  and  at  last  involves 
the  whole  mass."* 

1730.  "In  this  stage,  the  tuberculous  matter  is  of  two  differ- 
ent kinds  in  appearance — the  one  resembling  thick  pus,  but  with- 
out smell,  and  yellower  than  the  crude  tubercle;  the  other  a  mixed 
fluid,  one  portion  of  which  is  very  fluid,  more  or  less  transpa- 
rent, and  colourless,  unless  tinged  with  blood,  and  the  other  por- 
tion opaque,  of  a  caseous  consistence,  soft  and  friable.     In  this 
last  condition,  which  is  chiefly  observable  in  strumous  subjects, 
the  fluid  often  perfectly  resembles  whey,  having  small  portions 
of  curd  floating  in  it.     When  the  softening  of  the  tuberculous 
mass  is  completed,  this  finds  its  way  into  some  of  the  neigh- 
bouring bronchial  tubes,  and  as  the  opening  is  smaller  than  the 
excavation,  both  it  and  the  latter  remain  of  necessity  fistulous, 
even  after  the  complete  evacuation  of  the  tuberculous  matter.  It  is 
extremely  rare  to  find  only  one  such  excavation  in  a  tuberculous 
lung.     Most  commonly  the  cavity  is  surrounded  by  tubercles  in 
different  stages  of  their  progress,  which  as  they  successively  sof- 
ten, discharge  their  contents  successively  into  it,  and  thus  gra- 
dually form  those  irregular  and  continuous  excavations  so  fre- 
quently observable,  and  which  sometimes  extend  from  one  ex- 
tremity of  the  lungs  to  the  other.    Bands  composed  of  the  natu- 
ral tissue  of  the  organ,  condensed  as  it  were,  and  charged  with 
the  tuberculous  degeneration,  frequently  cross  these  cavities  in 
a  manner  something  resembling  the  columnse  corneas  of  the 
ventricles."  p.  278,  ib. 

1731.  "  In  proportion  as  an  excavation  discharges  its  contents, 
its  walls   become   covered  with  a  species  of  morbid  or  false 
membrane,  thin,  smooth,  white,  nearly  opaque,  of  a  very  soft 
consistence,  and  almost  friable,  so  that  it  can  be  readily  scraped 
off  with  the  scalpel.     This  membrane  is  quite  perfect,  covering 
the  whole  internal  surface  of  the  cavity.   Occasionally  this  mem- 
brane is  entirely  wanting,  and  the  walls  of  the  cavity  are  form- 
ed directly  by  the  natural  tissue  of  the  lungs,  which,  in  this  case 
is  commonly  condensed,  red,  and  charged  with  tuberculous  mat- 

•  Laennec,  p.  278. 


510  PHTHISIS    PULMONALIS,  OH    CONSUMPTION. 

ter  in  different  stages  of  its  development.  Bayle  thinks  that 
this  false  membrane  secretes  the  pus  expectorated  in  this  dis- 
ease— an  opinion  which  is  founded  on  the  analogy  existing  be- 
tween it  and  that  which  forms  on  the  surface  of  blisters  and  ul- 
cers. It  seems  certain,  however,  at  least  to  me,  that  the  greater 
part  of  the  matter  expectorated  is  the  product  of  the  bronchial 
secretion,  augmented  as  this  is  by  the  irritated  condition  of  the 
lungs.  I  do  not  assert  that  pus  is  not  formed  in  these  tubercu- 
lous excavations  at  all,  but  I  certainly  have  observed,  that  when 
these  are  lined  by  the  soft  membrane  described  above,  they  are 
often  entirely  empty,  and  that,  when  they  do  contain  any  puri- 
form  matter,  this  bears  by  no  means  so  great  a  resemblance  to 
the  sputa,  as  that  does  which  is  contained  in  the  bronchia."  p. 
280. 

5.  Encysted  Tubercles. 

1732.  These  are  developed  in  patches  under  the  false  mem- 
brane,  if  the  disease  has  been  long  stationary;  they  are  of  a 
grayish-white,  semitransparent,  with    a    cartilaginous  texture, 
and  adhere  closely  to  the  pulmonary  tissue.     These  patches  in- 
crease so  as  to  make  a  complete  lining  to  the  tuberculous  exca- 
vation, and  forms  a  continuous  surface  with  the  bronchial  tubes 
which  open  into  it.    Sometimes,  though  rarely,  the  semi-cartila- 
ginous membrane  is  seen  before  the  softening  of  the  tubercles, 
and  seem  to  be  of  the  same  date  with  them ;  this  is  the  encysted 
tubercle  of  Bayle. 

Effects  of  Tubercles. 

1733.  Death  may  take  place  without  any  ulcerous  excavations, 
when  tubercles,  even  of  a  small  kind,  are  very  numerous;  in  this 
case  they  have  not  become  sufficiently  soft  to  have  their  con- 
tents discharged  into  the  bronchia,  but  this  is  rare.  And  agreea- 
bly to  Laennec,  it  never  happens,  but  when  this  state  of  lungs 
is  complicated  with  some  other  severe  affection.     But  agreeably 
to  Broussafs"  and  Bayle,  as  stated  above,  death  may  take  place 
without  this  complication;  provided  perhaps  always,  that  the  tu- 
bercles are  advancing  towards  their  ultimate  softening.     When 
tubercles  are  inert,  that  is,  altogether  free  from  inflammation, 
they  have  not  been  found  to  incommode  the  system  in  the  slight- 
est degree ;  though  they  may  the  lungs  themselves  in  a  certain 
way.     For  tubercles  contain  nothing  acrid,  until  inflammation 
has  converted  them  into  suppurating  bodies;  then  access  of  air 
produces  all  the  terrible  consequences  of  phthisis. 

1734.  But  death  may  ensue  from  tubercles,  even  in  an  inert 


PHTHISIS   PULMONALIS,  OR    CONSUMPTION.  511 

state,  if  they  be  very  numerous;  as  they  must  necessarily  dimin- 
ish the  bronchial  surface  on  which  very  important  changes  of 
the  blood  take  place,  by  respiration.  Therefore,  all  the  mis- 
chief, which  the  want  of  due  oxygenation  may  produce,  will 
happen  in  this  case;  among  which  we  may  reckon,  all  that  can 
happen  from  the  want  of  the  just  and  proper  constitution  of  the 
blood  itself — secretion  and  nutrition  will  necessarily  be  imper- 
fect ;  and  we  are  all  aware  how  much  depends  upon  the  due  per- 
formance of  these  important  functions.  We  cannot  perhaps  esti- 
mate the  exact  degree  of  importance  that  may  attach  to  a  defi- 
ciency of  oxygen  in  the  blood;  nor  are  we  acquainted  precisely, 
with  the  chemical  changes  that  may  take  place  in  this  mass  from 
its  diminution  ;  nor  to  what  extent  this  may  influence  the  laws 
of  living  bodies;  yet  we  are  sensible  of  the  necessity  of  its  pre- 
sence, though  we  cannot  exactly  appreciate  the  consequences  of 
its  absence  unless  this  be,  nearly  absolute.  We  see,  however, 
that  debility  and  emaciation  have  been  the  constant  attendants 
on  this  state  of  the  lungs.  In  this  condition  of  tubercles,  it  would 
be  extremely  difficult,  if  not  impossible,  to  determine  that  they 
were  present  in  the  lungs — for  no  symptoms  discover  their  ex- 
istence ;  an  accidental  death,  that  is,  death  from  some  other 
cause,  alone  has  revealed  their  presence,  and  led  to  the  present 
conclusions. 

1735.  "When  there  are  few  tubercles,"  says  Laennec,  "we 
sometimes  find  them  all  excavated  after  death."  p.  282.     Now, 
these  are  the  cases  that  should  get  well,  agreeably  to  what  this 
author  has  said  ;  as  these  excavations  are  essential  to  a  cure;  and 
perhaps  would,  were  not  the  recuperative  powers  of  the  system 
too  much  exhausted  to  effect  restoration — hence,  the  truth  of  the 
remark  made  above  by  Laennec,  that  the  efforts  of  nature  to 
cure  this  disease,  was  rather  mischievous  than  otherwise;  as  the 
suppurating  of  the  tubercles,  necessarily  exposes  the  cavities  to 
the  presence  of  air;  hectic  fever,  the  most  wasting  of  all  the 
chronic  affections,  immediately  ensues,  and  the  patients  become 
exhausted  before  restoration  of  the  parts  can  be  accomplished. 
He  looks  upon  the  semi-cartilaginous  productions  as  an  effort  of 
nature  to  cure  the  disease. 

1736.  It  is  agreed  by  all  the  later  pathologists,  especially  by 
Bayle,  Broussais,  Laennec,  &c.  that  the  development  of  tuber- 
cles is  progressive  in  the  greater  number  of  instances;  but  cer- 
tainly not  in  a  regular  degree — this  sometimes  taking  place  very 
rapidly,  and  at  others  very  slowly.     But  whether  the  progress 
be  rapid  or  slow,  the  process  almost  always  ends  in  their  soften- 
ing, and  thus  producing  purulent  expectoration.     It  is  however 
not  uncommon  to  see  tubercles  in  all  their  various  states,  in  the 
same  lungs — these  are  "  1,  in  the  state  of  granulations,  either  gray 


512  PHTHISIS    PULMONALIS,  OR    CONSUMPTION. 

or  colourless,  and  semitransparent ;  2,  gray,  but  larger,  and  yel- 
low, and  opaque  in  the  centre ;  3,  yellow  and  opaque  through- 
out, but  still  firm  ;  4,  in  the  state  of  gray  tuberculous  infiltration, 
gelatinous,  or  yellow;  5,  softened, especially  in  the  centre;  6, in 
the  state  of  excavations,  more  or  less  completely  emptied."  La- 
ennec,  p.  282.* 

1737.  Laennec  says,  that  tubercles  first  begin  to  show  them- 
selves almost  always  in  the  top  of  the  upper  lobes,  "  more  par- 
ticularly the,  right.'"  Louis  however  has  been  led  from  his  ex- 
perience to  an  opposite  conclusion;  and  states  that  of  thirty- 
eight  cases  in  which  the  upper  lobe  was  entirely  disorganized, 
twenty-eight  of  the  instances,  were  on  the  left  side.t  Dr.  Forbes 


*  The  anatomical  character,  as  well  as  the  variety,  and  progress  of  tubercles, 
as  thus  laid  down,  has  been  contested  lately.  Thus  Andral,  (Clin.  Med.  Tom. 
III.  p.  4,)  denies,  that  the  granular  appearance  described  by  Bayle,  Laennec, 
and  Louis,  to  be  the  germs  of  tubercles.  He  says  this  appearance  is  owing1  to 
the  collapsing,  (affaisement,)  of  the  healthy  pulmonary  vesicles  which  surround 
the  indurated  and  inflamed  vesicles.  That  the  tubercular  matter  is  not  always 
placed  in  the  centre;  for  it  is  met  with  in  various  points,  as  well  as  at  the  cir- 
cumference of  the  granules;  and  thus  he  decides,  that  they  are  partially  in- 
flamed vesicles,  (pneumonies  ve"siculares  partielles.) 

He  thinks  also,  that  he  has  established,  that  the  gray  gelatinous  infiltration 
has  no  relation  to  tubercles.  That  it  presents  no  anatomical  character  differ- 
ent from  the  infiltrations  that  take  place  in  chronic  pneumony;  and  that  it  is  a 
morbid,  (sui  generis,)  secretion,  and  has  been  found  in  many  other  parts  of  the 
economy.  Cruveilheir  disputes  with  Andral  the  originality  of  this  suggestion. 
Bouillaud  thinks,  that  the  name  of  tubercle  can  only  properly  apply  to  such 
bodies  in  the  lungs  as  have  been  called  tuberculous  abscesses,  softened  tuber- 
cles, tuberculous  matter,  vomica,  &c.  if  such  an  improper  term  is  to  be  retain- 
ed in  medical  science. 

Andral  thinks  he  has  satisfactorily  proved  from  many  dissections,  that  the 
tubercle  always  begins  from  a  small  point  of  liquid  matter;  yellow,  or  abso- 
lutely analogous  to  pus;  and  that  in  other  portions  of  the  same  lung,  similar, 
but  larger  collections,  and  of  which  the  periphery  was  concreted  by  the  in- 
fluence of  absorption  on  its  surface;  while  the  centre  was  still  liquid.  He 
therefore  concludes,  that  tubercles  are  nothing  more  than  hardened  pus.  Of 
this  opinion  is  also  Bouillaud.  We  would  only  ask,  if  this  pus  differs  in  any 
respect  from  the  mildest  and  most  healthy  pus?  If  it  do,  that  difference  must 
have  been  imposed  upon  it,  during  its  secretion;  and  consequently  the  part 
forming  this  pus  is  the  diseased  part,  and  not  the  fluid  which  it  yields.  No 
one  would  certainly  say,  that  cancer  consists  of  a  fetid,  sanguineous  and  acrid 
pus — or  that  the  whey-like  fluid,  discharging  from  a  diseased  gland,  was  scro- 
fula; the  effect  is  here,  evidently  mistaken  for  the  cause.  On  the  whole, 
as  far  as  we  are  capable  of  judging,  we  do  not  think  that  the  account  of  tuber- 
cles as  laid  down  by  Bayle  and  Laennec  is  at  all  impaired  by  the  suggestions 
of  Andral,  and  Cruveilheir.  Besides,  the  whole  economy  of  these  bodies,  show 
how  widely  they  differ  from  every  other  inflammatory  production;  1,  they 
acquire  a  cartilaginous  hardness  when  suppurating;  2,  the  cavity  from  which 
the  pus  discharges  is  lined  by  a  peculiar  membrane,  from  the  surface  of  which 
no  pus  is  secreted  after  the  first  portion  has  discharged  itself;  3,  and  that  the 
cavity  never,  or  but  extremely  rarely  fills  up,  as  the  excavations  of  common 
abscesses  do. 

f  Recherches,  p.  7,  8,  9. 


PHTHISIS    PULMONALIS,   OR    CONSUMPTION.  513 

appears  doubtful  whether  his  cases  were  sufficiently  numerous, 
(123,)  to  unsettle  the  experience  of  Laennec.  When  large  tu- 
berculous excavations  are  found,  it  is  for  the  most  part  in  these 
places. 

1738.  "It  is  by  no  means  uncommon,"  says  Laennec,  "  to 
meet  with  cavities  of  this  kind,  in  the  situations  just  named, 
when  the  rest  of  the  lungs  are  quite  sound,  and  do  not  contain  a 
single  tubercle;  but  in  this  class  of  cases,  the  patient  during  life, 
has  frequently  exhibited  no  signs  of  phthisis,  or  only  equivocal 
ones,  and  has  died  of  some  other  disease."  p.  282.     These  are 
very  interesting  facts,  and  should  be  borne  in  mind;  we  have 
already  adverted  to  this  condition  of  the  pulmonary  organs,  to 
show  how  insidious  in  some  instances  this  disease  is.  Dr.  Forbes 
supposes,  that  this  was  the  condition  of  the  lungs  of  Laennec 
himself.  "  There  can  be  no  doubt,"  says  Dr.  Forbes,  "  that  the 
disease  of  which  Laennec  died  was  phthisis  pulmonalis;  and  it 
is  somewhat  curious,"  he  adds,  "  that  he  shared  the  fate  of  some 
of  his  most  illustrious  predecessors,  in  falling  a  victim  to  a  dis- 
ease, the  nature  of  which  he  had  taken  particular  pains  to  illus- 
trate.  Lancisi,  and  Corvisart  died  of  diseased  heart ;  and  his  own 
friend,  Bayle,  sunk,  like  himself,  under  the  ravages  of  the  dis- 
ease of  which  he  had  been  the  most  successful  illustrator,  and  of 
the  inevitable  fatality  of  which  he  had  been  the  most  strenuous 
asserter.     M.  Laennec's  case  presented  all  the  external  symp- 
toms of  consumption ;  and  its  nature  was  moreover,  fully  con- 
firmed by  the  very  art  which  he  had  himself  discovered.   Before 
he  left  Paris,  Drs.  Racamier  and  Meriadec  Laennec  discovered 
imperfect  but  evident  pectoriloquism,  under  the  left  clavicle, 
and  in  the  supra-spinal  fossa  of  the  left  side."* 

1739.  It  is  not  uncommon  to  find  in  the  same  lung  evidences 
of  two  or  three  successive  crops  of  tubercles.     The  oldest  of 
which,  generally  occupies  the  top  of  the  lung,  and  is  in  a  state 
of  excavation,  the  second,  situated  around  and  below  these,  are 
yellow,  and  of  no  great  size;  the  third  are  crude  miliary  tuber- 
cles, and  are  situated  lower.t 

*  Life  of  Laennec,  p.  xxi. 

f  The  progressive  nature  of  tubercles  would  seem  to  prove,  that  they  are 
vital  and  organized  bodies,  notwithstanding  the  cavilling  of  Bouillaud  upon  this 
point.  Mr.  B.  has  denied,  (Journal  des  Progres  for  1827,  Vol.  IV.  p.  149  et 
suiv.)  to  tubercles,  either  of  the  properties  just  named.  With  a  view  to  prove 
this,  he  gives  the  definition  of  an  organ  from  Beclard;  who  says,  that  "  every 
organized  body  is  formed  of  particles  intermixing  and  crossing  each  other, 
with  a  tissue  forming  or  resembling  areolx,  with  particular  cavities  for  fluids." 
"  Whereas,  he  says  all  who  have  described  the  tubercle,  declare  it  to  have  a 
close,  homogeneous  structure  (Bayle)  formed  of  a  mass  of  matter  more  or  less 
solid;  but  that  its  greatest  solidity  does  not  exceed  that  of  cheese,  and  which 
softens  down  to  the  consistence  of  pus.  Certainly,  there  is  nothing  here  which 
resembles  organized  matter."  "  Moreover,  Stark,  (the  first  who  studied  the 

65 


514  PHTHISIS    PULMONALIS,    OR    CONSUMPTION. 

1740.  Various  parts  of  the  body  are  subject  to  tubercles  be- 
sides the  lungs;  indeed  all  the  larger  glands,   and  almost  every 
surface  or  part  that  is  susceptible  of  active  inflammation  appears 
obnoxious  to  them.   Some  however  are  more  liable  than  others ; 
Laennec  arranges  them  as  follows — "  the  bronchial,  the  medi- 
astinal,  the  cervical,  the  mesenteric,*  and   the   other  glands 
throughout  the  body:  the  liver — in  which  they  attain  a  large 
size,  but  rarely  come  to  maturation ;  the  prostate ;  the  surface 
of  the  peritoneum  and  pleura;  the  epididymus,  the  vasa  defer- 
entia,  the  testicle,  spleen,  heart,  uterus,  brain  and  cerebellum," 
&c.  &c.  p.  284. 

1741.  It  seems  indeed  proved  by  the  pathological  investigations 
of  Louis,  that  it  is  sufficient,  that  the  lungs  possess  them,  to  have 
them  develope  themselves  in  other  portions  of  the  body;  though 
this  does  not  appear  to  have  been  the  opinion  of  Laennec,  who 
says,  "  sometimes,  but  very  rarely,  the  production  of  tubercles 
begins  in  the  parts  just  named;  especially  in  the  mucous  mem- 
brane of  the  intestines  and  in  the  lymphatic  glands;  and  their 
appearance  in  the  lungs  is  the  result  of  a  secondary  formation." 
p.  285. 

1742.  But  on  the  other  hand,  Louis  declares  he  never  found 
tubercles  in  any  other  organ,  without  their  existing  in  the  lungs, 
and  this  being  essential  to  their  development.     He  thinks  him- 
self justified  in  this  opinion,  by  having  observed,  with  a  single 
exception  that  the  tuberculous  matter  was  always  much  more 
advanced  in  the  lungs  than  in  other  parts.     We  think  this  ren- 

subject  with  attention,  and  whose  description  is  strikingly  true,  and  who  if  he 
had  been  better  known,  would  have  prevented  both  Bayle  and  Laennec  the 
laborious  investigations  they  have  made  upon  this  subject,)  endeavoured  in 
vain  to  force  injection  into  these  little  bodies;  he  could  never  make  it  pass  be- 
yond the  pulmonary  tissue  that  surrounded  them.  Cruveilheir  repeated  these 
experiments  with  the  same  results;  and  therefore  did  not  hesitate  to  declare, 
that  these  bodies  were  absolutely  inorganic.  And  Andral  having  never  been 
able  to  trace  any  vessels,  fibres,  laminae,  in  a  word,  organization,  has  declared 
a  like  opinion."  p.  163. 

Now,  we  would  ask  any  candid  mind,  whether  it  would  consent,  to  either 
the  definition  of  an  "  organ,"  or  to  the  proofs,  adduced,  that  the  parts  upon 
which  these  experiments  were  made,  were  devoid  of  organization?  Thus  car- 
tilage, has  scarcely  a  single  mark  laid  down  in  the  definition;  yet,  who  doubts 
of  either  its  vitality,  or  its  organization.  Has  injection  ever  been  forced  into 
its  substance,  when  in  a  healthy  state;  or  into  that  of  tendon,  or  bone;  yet,  are 
these  parts,  decidedly  living  and  as  decidedly  organized?  Has  it  ever  pene- 
trated the  medulla  of  the  cylindrical  bones?  yet  this  substance  is,  both  vital 
and  organized,  though  possessing  perhaps,  even  less  tenacity  or  firmness,  than 
the  tubercle,  which  is  denied  these  properties,  because  it  does  not  possess 
more  solidity  than  cheese — nay,  who  will  deny  the  vitality  of  the  blood,  or  of 
the  male  semen,  though  they  are  fluids? 

*  Louis  tells  us  he  found  the  mesenteric  glands  more  frequently  affected, 
(that  is,  in  one -fourth,)  than  any  others.  The  spleen  and  kidneys  were  equally 
affected;  that  is  in  one-sixth  of  the  cases. 


PHTHISIS  PULMONALIS,   OR    CONSUMPTION.  515 

ders  the  matter  probable,  but  by  no  means  makes  it  certain ;  as 
some  circumstances  connected  with  the  economy  of  the  lungs,  or 
the  other  viscera  may  make  the  development  much  more  rapid, 
or  slow,  than  in  other  portions  of  the  body.  That  there  are  parts 
of  the  body  in  which  the  development  is  much  more  excessive 
than  in  others  cannot  be  doubted;  as  the  cavernous  excavations 
are  much  larger  in  the  upper  portions  of  the  lungs,  than  in  the 
middle  or  inferior  parts.  And  Broussais  gives  us  an  instance  in 
which  "  the  liver  and  spleen  were  tuberculous ;  in  the  former,  the 
tubercles  were  almost  miliary,  and  without  pus  in  the  centre ; 
while  the  spleen  appeared  to  be  transformed  into  a  mass  of  tu- 
bercles, several  of  which  were  very  large,  and  softened  either  en- 
tirely or  in  part."* 

1743.  Besides,  it  does  not  appear  from  dissection,  that  tubercles 
will  develope  themselves  in  other  portions  of  the  body,  merely 
because  the  lungs  are  occupied  by  them ;  of  this  kind  is  Obs.  xl. 
of  Broussais.     He  declares,  that  the  lungs  were  "sowed  with 
little  miliary  grains;"  but  all  the  abdominal  viscera  were  sound. 
But  we  must  not  omit  to  state,  that  he  appears  to  disbelieve  in 
this  instance,  his.  own  statement;   for  in  a  note  he  exclaims, 
"  doutez,  lecteurs,  avec  moi  meme."  (p.  23.)  He  appears  to  have 
allowed  a  subsequent  theory  to  call  in  question   his  own  facts. 
But  we  believe  we  could  bring  many  facts  to  prove,  that  the 
progress  of  tubercles  towards  suppuration  in  the  lungs,  is  not 
always  in  advance  of  those  in  other  parts  of  the  body.    Thus  in 
Obs.  xlii.  of  the  same  author,  we  do  not  find  they  were  more 
advanced  in  the  mesentery,  than  they  were  in  the  lungs.     We 
do  not  think  therefore,  the  opinion  of  Louis,  that  "  it  is  essential, 
that  tubercles  exist  in  the  lungs,  to  have  them  developed  else- 
where," is  well  sustained.     The  predisposition  to  this  develop- 
ment, most  probably  exists  in  the  whole  of  the  lymphatic  system ; 
and  therefore  any  portion  of  it,  under  the  influence  of  certain 
exciting  causes  may  have  these  bodies  developed  in  it  with  as 
much  certainty,  if  not  with  equal  rapidity,  as  in  the  lungs. 

1744.  We  therefore  have  as  much  reason  to  believe,  that  the 
development  of  tubercles  in  other  parts  of  the  body  may  antici- 
pate their  development  in  the  lungs,  as  to  believe  with  Louis, 
that  this  operation  must  commence  in  the  pulmonary  tissue.  But 
be  the  commencement  where  it  may,  we  can  have  no  hesitation 
to  believe  that  it  will  sooner  or  later  involve  the  whole  of  the 
lymphatic  system,  as  there  will  constantly  be  a  sympathetic  in- 
fluence exerting  itself  to  this  effect. 

1745.  Some  of  the  organic  changes  are  not  less  remarkable 
than  constant;  thus  the  cellular  and  adipose  membrane  is  absorb- 

*  Phlegm.  Chron.  Vol.  EL  p.  40. 


516  PHTHISIS   PULMONALIS,    OR    CONSUMPTION. 

ed  to  a  degree  perhaps  that  no  other  disease  occasions.  The 
bones  have  their  diameters  diminished,  though  their  length  re- 
mains unaffected;  while  the  blood-vessels  are  reduced  in  capa- 
city, merely  from  less  blood  being  furnished  to  them.  The  chest 
of  phthisical  patients  is  usually  narrow,  and  oftentimes  contract- 
ed ;  the  latter  arises  agreeably  to  Laennec,  from  1,  the  pleurisies 
to  which  such  patients  are  extremely  subject,  both  before  and 
during  the  course  of  their  disease,  and  which  give  rise  to  a  con- 
traction of  the  chest,  when  they  terminate  favourably ;  2,  the  at- 
tempts which  nature  makes  to  cure  phthisis.  The  serous  mem- 
branes and  skin  are  very  pale  and  free  from  blood  in  these  cases; 
while  the  muscles  and  heart,  are  usually  of  a  bright  red.  Ulcers, 
which  penetrate  the  intestines  sometimes,  especially  the  smaller, 
near  their  termination,  are  not  unfrequently  found. 

1746.  Louis  says,  that  ulcers  existed  in  the  small  intestines 
and  not  unfrequently  in  the  large ;  in  the  former  this  happened 
in  five-sixths  of  the  patients  he  examined,   (p.  175.)     Laennec 
observes,  that  phthisical  patients  are  not  very  much  disposed  to 
sceptical  decomposition;  since  patients  in  this  disease,  are  much 
less  liable  to  gangrenous  eschars  on  the  back,  from  long  confine- 
ment, than  in  many  others,  and  that  their  bodies  are  slow  in 
running  into  putrefaction. 

Of  the  Cause  of  Tubercles. 

1747.  Laennec  has  very  justly  observed  in  his  section  on  the 
"examination  of  the  question,  whether  or  not  tubercles  are  the 
consequence  of  inflammation,"  that  the  ancients  attributed  to  it, 
all  the  accidental  productions  of  the  system  with  which  they 
were  acquainted,  and  that  this  opinion  prevailed,  until  Bayle 
exploded  it  by  facts.     It  is  well  known,  that  Broussais  not  only 
adopted  this  notion,   but  warmly  espouses  it  at  this  moment. 
With  a  view  to  settle  this  question,  Laennec  has  examined  the 
agency  of  the  inflammatory  affections  of  the  chest  in  detail,  and 
his  conclusions  are  altogether  adverse  to  those  of  the  celebrated 
pathologist  just  named.*     He  first  treats  of — 

•  "  One  of  the  most  enlightened  pathologists  of  the  age,  Dr.  Allison  of  Edin- 
burgh, seems  to  think  that  tubercle  is  one  of  the  products  of  inflammation;  and 
certainly  this  variety,  (the  medullary,)  of  tubercle,  if  such  it  may  be  fairly 
considered,  would  give  a  strong  colouring  to  the  opinion.  But  then  it  might 
be  justly  asked,  if  tubercle  be  the  mere  product  of  inflammation,  how  does  it 
happen  that  we  see  the  remains  of  inflammation  acute  and  chronic,  without 
any  vestige  of  that  body?  At  all  events  therefore,  if  inflammation  be  connect- 
ed with  the  origin  of  tubercle,  some  other  condition  must  concur  in  the  human 
body,  since  inflammation  simply  of  itself  is  not  adequate  to  produce  the  effect 
in  ordinary  cases,  even  where  the  texture  of  the  part,  and  the  age  of  the  pa- 
tient, are  the  most  favourable  for  its  development." — Armstrong's  Morbid  JLna- 
tomy,  yc.jj.  73, 


PHTHISIS    PULMONALIS,    OR    CONSUMPTION.  517 


{t*flcute  Peripneumony." 

1748.  From  what  he  has  observed  of  this  disease  and  its  con- 
srquences,  he  declares  it  to  be  his  opinion,  and  thinks  it  would 
b    the  opinion  also  of  every  unprejudiced  practitioner  of  obser- 
vation, that  "phthisis  very  rarely  shows  itself  after  acute  pneu- 
monia." "And  that  even  where  this  sequence  is  observed,  it  is 
impossible  to  say  whether  the  pneumonia  has  given  rise  to  the 
tubercles,  or  whether  these,  acting  as  irritating  bodies,  have  not 
excited  the  pneumonia.     On  the  authority  of  pathological  ana- 
tomy, the  solution  of  the  question  is  much  more  simple ;  since 
it  is  certain  that  we  very  rarely  find  tubercles  in  the  lungs  of 
those  who  have  died  of  pneumonia,  and  that  the  greater  number 
of  consumptive  subjects  exhibit  no  symptom  of  this  disease  dur- 
ing the  progress  of  their  fatal  malady,  nor  any  trace  of  it  after 
death."  (p.  290.)  And  were  this  true,  he  thinks,  that  the  transi- 
tion of  one  disease  into  the  other  might  be  traced,  as  is  done  be- 
tween the  inflammatory  engorgement,  and  the  pulmonary  abscess; 
but  this  is  far  from  being  the  case.   (p.  291.) 

1749.  He  confesses  that  acute  pneumonia,  and  tubercles,  oc- 
casionally co-exist ;  but  this  is  rare ;  when  the  frequency  of  both 
diseases  are  taken  into  consideration.     And  that  in  nineteen- 
twentieths  of  this  complication,  the  tuberculous  affection  pre- 
cedes ;  and  we  may  therefore  infer,  that  the  tubercles  are  the 
occasional  cause  of  the  pneumonia,  or  that  the  diseases  though 
existing  together,  have  no  etiological  relation  to  each  other,  (p. 
292.)     He  next  considers — 

"  Chronic  Pneumonia."* 

1750.  This  disease  he  declares  to  be  rare,  and  tfoat  the  physi- 
cal character  of  this  affection  differs  much  from  tubercles.    That 


*  The  observations  of  Laennec  upon  the  influence  of  inflammatory  affec- 
tions of  the  chest,  in  the  production  of  tubercles,  are  strongly  supported  by 
Louis;  (Recherches  sur  la  Phthisic,  p.  522,  et  suiv.)  He  informs  us,  that  of 
eighty  phthisical  patients,  whose  previous  histoiy  he  had  ascertained,  only  se- 
ven had  been  affected  with  peripneumony;  of  these  there  were  four,  who  had 
been  perfectly  free  from  any  affection  of  the  chest,  for  several  years  before  the 
onset  of  phthisis.  He  agrees  with  Laennec,  that  tubercles  select  most  fre- 
quently the  upper  portion,  or  lobes,  of  the  lungs  for  their  seat,  while  peri- 
pneumony invades  the  lower.  He  also  states,  that  pneumonia  rarely  affects 
both  lungs,  while  phthisis  almost  always  does;  and  adds  that  the  former  is  most 
common  to  men,  while  the  latter  is  so  in  females.  He  applies  the  same  re- 
marks to  pleurisy  and  catarrh— but  with  this  remarkable  fact,  that  in  chronic 
pleurisy,  he  found  as  many  tubercles  in  the  lung  of  the  sound,  as  in  the  lung 
of  the  diseased  side.  Of  the  eighty  patients  above  specified,  twenty-three  only 
had  been  particularly  subject  to  catarrh;  and  out  of  one  hundred  and  forty-nine 


518  PHTHISIS   PULMONALIS,   OR    CONSUMPTION. 

in  chronic  peripneumony  the  inflammation  is  confined  to  the  air- 
cells,  which  are  pressed  closely  together,  without  any  intervening 
space,  and  are  of  a  reddish,  greenish,  or  yellow  colour;  yet  these 
bear  no  resemblance  to  the  miliary  tubercles. 

"  Catarrh," 

1751.  Laennec  makes  next  in  order.     He  thinks  that  the  po- 
pular opinion,  that  consumption  is  the  consequence  of  a  neglect- 
ed cold,  to  be  entirely  without  foundation.     He  admits,  that  in 
most  instances  of  phthisis,  the  first  symptoms  are  catarrhal ;  but 
that  it  is  equally  true  that  very  large  and  numerous  tubercles  are 
found  without  any  sign  of  catarrh.     Nor  can  they  be  the  result 
of  former  catarrhs,  since  they  are  found  in  those  who  may  never 
have  had  catarrh.     He  agrees,  that  a  pulmonary  catarrh  may 
come  on  in  a  state  of  apparently  perfect  health,  and  yet  be  the 
first  evidence  of  a  tuberculous  phthisis ;  but  this  case  however, 
may  have  existed  a  long  time  in  a  latent  state;  since  examination 
detects  all  the  physical  signs  of  tubercles,  and  sometimes  of  even 
tuberculous  excavations. 

1752.  On  the  other  hand,  many  persons  have  catarrh  repeated 
several  times  a  year;  yet  few  of  them  become  phthisical.     In- 
deed, some  live  to  an  advanced  age  without  becoming  phthisical, 
though  they  may  have  had  a  mucous  catarrh  for  many  years.  He 
however  does  not  wish  to  be  understood  as  believing,  that  ca- 
tarrh is  a  preventive  to  consumption,  though  he  concludes  it  is 
not  the  cause  of  it ;  that  no  anatomical  marks  show  the  transition 
of  the  one  complaint  into  the  other.    The  seat  of  these  affections 
are  altogether  different — catarrh  consists  in  an  inflammation  of 
the  mucous  membrane  of  the  bronchia,  while  tubercles  are  acci- 
dental productions,  or  foreign  bodies  occupying  the  substance  of 
the  lungs,  but  are  extremely  rarely  found  in  the  bronchial  mem- 
brane itself,  even  when  the  lungs  are  completely  charged  with 
them.  (p.  296.) 


"  Pleurisy" 


1753.  Next  occupies  his  attention.  In  cases  of  severe  pleu- 
risy, "  the  inflammatory  afflux"  is  not  propagated  to  the  lung; 
on  the  contrary,  the  copious  secretion  of  serum,  which  always 

cases  of  catarrh  for  which  he  prescribed,  only  fifty-two  happened  to  women. 
From  these  facts  it  is  evident,  that  a  merely  inflamed  condition  of  the  lungs, 
is  not  sufficient  to  generate  or  produce  tubercles;  and  at  first  sight,  it  might 
even  appear,  that  it  is  not  even  necessary  to  their  development,  where  a  pre- 
disposition really  exists;  but  of  this,  we  must  not  be  too  certain,  until  we  know 
more  of  the  physical  condition  of  inflamed  parts,  than  we  do  at  present.  (See 
note,  p.  16.) 


PHTHISIS   PULMONALIS,   OR   CONSUMPTION.  519 

takes  place  in  this  disease,  (see  Sect,  on  Pleurisy,)  compresses 
it  against  the  mediastinum,  and  thus  diminishes  its  stock  of  fluids. 
In  cases  of  empyema,  of  even  a  year's  standing,  the  lung  is  con- 
stantly found  sound,  except  that  it  is  strongly  compressed.  From 
all  his  observations,  he  concludes,  that  pleurisy  is  frequently  the 
effect  of  tubercles  in  the  lungs.  And  "from  all  that  has  gone 
before,"  he  thinks,  "we  are  authorized  to  conclude,  that  tuber- 
cles are  not  the  product  of  inflammation  of  any  one  of  the  consti- 
tuent textures  of  the  lungs." 

1754.  "On  the  contrary,  a  multitude  of  facts  prove,  that  the 
development  of  tubercles  is  the  result  of  a  general  condition  of 
the  body ;  that  it  takes  place  without  previous  inflammation;  and 
that,  when  inflammation  coincides  with  the  tuberculous  affection, 
it  is  most  frequently  posterior  to  it  in  its  origin."  p.  297.  He 
thinks  this  is  abundantly  proved,  by  the  progress  that  tubercles 
make  in  scrofulous  glands.  1.  They  swell  in  many  cases,  and 
remain  in  this  state  for  a  long  time,  without  redness,  or  even  the 
surrounding  parts  being  so.  2.  It  is  sometimes  several  years  be- 
fore inflammation  occurs  in  the  parts.  But  when  this  takes  place, 
the  softening  of  the  tuberculous  matter  is  hastened.  "  Sometimes, 
however,  not  only  the  softening  of  this  matter,  but  even  the  per- 
foration of  the  skin,  and  the  discharge  of  the  pus  take  place  with- 
out any  distinct  mark  of  inflammation."  Ib.* 

*  Perhaps  there  is  less  difference  in  fact  in  the  opinion  of  Laennec  and  those 
who  have  declared  inflammation  to  be  the  cause  of  tubercles,  (as  Sylvius, 
Wepfer,  Tralles,  &C.-J-)  and  lately,  and  especially  Broussais;  and  we  may  add, 
indeed,  Andral,  than  would  appear  at  first  sight.  The  absence  of  inflammation 
in  the  development  of  tubercles,  as  stated  by  Laennec,  is  only  proved  by  the 
non-existence  of  redness.  But  it  still  remains  to  be  proved  that  redness  is  a 
sine  qua  non  to  inflammation;  indeed,  we  are  of  opinion,  that  a  condition  may 
exist  in  a  part,  and  this  to  a  degree  that  will  eventuate  in  suppuration,  without 
redness  accompanying  the  process  in  any  of  its  stages.  This  appears  to  be 
proved  in  phlegmasia  dolens;  and  especially  in  such  cases  of  it  as  run  on  to 
suppuration;  and  also  in  certain  cases  of  milk  abscess,  as  they  are  called.  Of 
the  former,  the  phlegmasia  dolens  running  on  to  suppuration,  we  can  only 
speak  from  the  information  of  others,  (Ferriar's  Med.  Hist. )  in  the  latter,  we- 
can  declare  its  occurrence,  in  a  number  of  instances.  Yet  in  all  these  cases, 
every  other  phenomenon  of  inflammation  were  present,  namely,  swelling,  heat, 
and  pain.  Broussais  notices  this  condition  of  a  part,  and  calls  it  "irritation;" 
this  it  must  be  acknowledged,  is  not  very  precise;  and  perhaps  it  conveys  no 
idea  of  the  actual  condition  of  the  part  so  circumstanced.  It  is  only  by  a  con- 
sent of  the  mind,  that  this  state  is  admitted,  as  no  positive  proof  can  be  offered 
beyond  what  has  just  been  stated,  namely,  that  swelling,  heat,  and  pain  may 
alone  exist  in  a  suppurating  part,  (without  the  circumstance  of  redness  to  con- 
stitute it  inflammation  by  definition,)  be  considered  as  such.  Now,  it  is  every 
way  probable,  that  the  several  phenomena  just  mentioned  are  always  anterior 
to  the  error  loci  of  the  red  particles  of  the  blood,  which,  "  definition"  makes 
essential  to  the  existence  of  inflammation.  Some  change  certainly  must  take 
place  in  the  parts,  when  tubercles  are  about  to  alter  their  condition — in  what 

t  Young  on  Consumption. 


520 


PHTHISIS    PULMONALIS,    OR    CONSUMPTION. 


1755.  There  is  perhaps  no  belief  more  universal    than  that 
haemoptysis  is  the  cause  of  consumption.    But  neither  Laennec, 
Broussais,  nor  Louis,*  is  of  this  -opinion — they  all  agree  in  the 
frequency  of  its  appearance  in  phthisical  patients,  and  they  also 
concur,  that  it  is  often  the  consequence  of  tubercles,  but  that  it 
is  never  the  cause  of  them ;  but  of  this  more  when  we  come  to 
treat  of  this  haemorrhage. 

*'  Of  the  Depressing  Passions  as  Causes  of  Phthisis." 

1756.  Laennec  declares  the  depressing  passions  to  be  highly 
instrumental  in  the  production  of  phthisis,  especially  if  they  be 
strong  and  long-continued.     In  large  cities,  he  seems  to  view 
them  as  the  sole  causes.     He  thinks  this  is  owing  to  the  more 
frequent  relations  the  inhabitants  have  with  each  other,  and  the 
greater  prevalence  of  immorality,  shutting  out  many  times  all 
consolation. 

1757.  He  relates  in  proof  of  the  instrumentality  of  the  de- 
pressing passions  in  the  production  of  phthisis,  one  of  the  most 
remarkable,  as  well  as  interesting  histories,  we  ever  remember 
to  have  met  with.    I  shall  relate  it  in  his  own  words,  or  at  least 
in  the  words  of  his  successful  and  accurate  translator. 


does  this  change  consist?  can  any  one  point  it  out?  is  there  any  physiological 
fact  that  will  explain  it?  in  certain  cases,  may  not  the  vis  a  tergo  be  inadequate 
to  the  forcing  of  the  red  globules  into  the  capillaries  to  constitute  inflamma- 
tion, by  "  definition?"  yet,  may  not  all  the  other  conditions  of  this  morbid  state 
exist,  without  this  contingency?  May  we  not  understand  the  "irritation"  of 
Broussais,  to  consist  of  that  state  of  inflammation  in  which  the  red  globules  are 
not  forced  into  the  capillaries?  If  this  be  admitted,  will  it  not  account  for  the 
disappointments  now  and  then  met  with  in  post  mortem  examinations,  where 
every  symptom  declared  the  presence  of  inflammation,  agreeably  to  its  full 
"  definition"  to  have  been  the  cause  of  death  ?  We  ask,  may  we  not  understand 
the  "  irritation"  of  Broussais,  to  consist  in  the  condition  of  such  parts  as  do  not 
circulate  red  blood,  as  inflammation  unattended  by  the  "error  loci"  of  red 
globules?  For  neither  he  nor  Goupil,  the  expounder  of  his  doctrines,  do  not 
look  upon  it  exactly  in  this  light.  They  say  that  irritation  commences  in  the 
nerves,  and  from  these  cords,  it  is  propagated  to  the  capillary  vessels  of  other 
parts. 

On  the  other  hand,  we  have  many  facts  to  prove,  that  violent  inflammation 
of  the  substance  of  the  lungs  from  even  mechanical  causes  have  existed  for 
a  long  time,  and  have  even  proceeded  to  ulceration,  without  causing  the  deve- 
lopment of  tubercles;  and  Broussais  himself  furnishes  at  least  one  remarkable 
case  of  this  kind.  (See  Monroy's  case,  Ob.  liii.  Vol.  II.  p.  103.) 

*  Louis  informs  us,  that  "for  the  last  three  years,  he  hud  questioned  every 
patient  that  came  under  his  care,  whether  they  had  ever  had  a  spitting  of 
blood,  and  he  was  constantly  answered  in  the  negative,  except  some  few  who 
may  have  received  a  severe  blow  on  the  chest,  or  women  who  may  have  had 
a  sudden  suppression  of  the  menses.  But  with  these  exceptions  he  agrees, 
that  this  symptom  indicates  very  constantly  the  presence  of  tubercles  in  the 
lunge." — RechercJics,  p.  194. 


PHTHISIS   PULMONALIS,  OR   CONSUMPTION.  521 

1758.  "I  had  under  my  own  eyes,  during  a  period  of  ten 
years,  a  striking  example  of  the  effects  of  the  depressing  passions 
in  the  producing  of  phthisis,  in  the  case  of  a  religious  association 
of  women,  of  recent  foundation,  and  which  never  obtained  from 
the  ecclesiastical  authorities  any  other  than  a  provisional  tolera- 
tion on  account  of  the  extreme  severity  of  its  rules.     The  diet 
of  these  persons  was  certainly  very  austere,  yet  it  was  by  no 
means  beyond  what  nature  could  bear.     But  the  ascetic  spirit 
which  governed  their  minds,  was  such  as  to  give  rise  to  conse- 
quences no  less  serious  than  surprising.     Not  only  was  the  at- 
tention of  these  women  habitually  fixed  on  the  most  terrible 
truths  of  religion,  but  it  was  the  constant  practice  to  try  them 
by  every  kind  of  contrariety  and  opposition,  in  order  to  bring 
them  as  soon  as  possible  to  an  entire  renouncement  of  their  own 
proper  will.     The  consequences  of  this  discipline  were  the  same 
in  all ;  after  being  one  or  two  months  in  the  establishment,  the 
catamenia  became  suppressed;  and  in  the  course  of  one  or  two 
months  thereafter,  phthisis  declared  itself!  As  no  vow  was  taken 
in  this  society,  I  endeavoured  to  prevail  upon  the  patients  to 
leave  the  house  as  soon  as  the  consumptive  symptoms  began  to 
appear;  and  almost  all  those  who  followed  my  advice  were  cured, 
although  some  of  them  exhibited  well-marked  indications  of  the 
disease.  During  the  ten  years  I  was  physician  to  this  association, 
I  witnessed  its  entire  renovation  two  or  three  different  times, 
owing  to  the  successive  loss  of  all  its  members,  with  the  excep- 
tion of  a  small  number,  consisting  chiefly  of  the  superior,  the 
grate  keeper,  and  the  sisters  who  had  charge  of  the  garden, 
kitchen,  and  infirmary.     It  will  be  observed  that  these  indivi- 
duals were  those  who  had  the  most  constant  distractions  from 
their  religious  tasks,  and  that  they  also  went  out  pretty  often 
into  the  city,  on  business  connected  with  the  establishment." 
p.  328. 

"Is  Phthisis  a  Contagious  Disease?" 

1759.  There  is  considerable  diversity  of  opinion  upon  this 
subject.    We  have  never  in  a  single  instance  met  with  a  fact  that 
inclined  us  to  the  belief  that  phthisis  is  a  contagious  disease;  and 
we  have  certainly  witnessed  many  cases,  in  which  it  would  have 
propagated  itself,  had  it  been  capable  of  this  effect.     The  best 
writers,  and  at  the  same  time  the  closest  observers,  such  as  Laen- 
nec,  Young,  Louis,  Forbes,  &c.  are  of  opinion,  that  it  is  not  a 
contagious  disease;  though  Dr.  Forbes  recommends  caution,  in 
making  up  our  minds  upon  this  subject,  by  saying,  "in  a  prac- 
tical question,  of  such  high  importance  as  the  present,  it  is  cer- 
tainly the  duty  of  every  medical  man  to  act  cautiously,  and  not 

66 


522  PHTHISIS    PULMONALIS,   OR    CONSUMPTION. 

unnecessarily  expose  the  friends  of  his  phthisical  patients  to  a 
risk,  which,  although  he  may  deem  it  problematical  or  even 
visionary,  may  not  be  so  in  reality."* 

1760.  Laennec  says,  "in  France  at  least,  it  does  not  appear 
to  be  contagious.     We  frequently  observe  among  the  poorer 
classes,  a  numerous  family  sleeping  in  the  same  apartment  with 
a  consumptive  patient,  and  a  husband  occupying  to  the  last,  the 
same  bed  with  his  wife,  without  any  communication  of  the  dis- 
ease. The  woollen  apparel  and  the  beds  of  consumptive  subjects, 
which  it  is  the  custom  in  some  countries  to  burn,  are  not  even 
generally  washed,  much  less  destroyed  in  France,  and  yet  I  have 
never  seen  the  disease  communicated  by  them."  p.  330.     He,  it 
is  true,  seems  rather  inclined  to  the  belief,  that  we  may  produce 
the  matter  of  tubercle,  by  the  direct  application  of  some  of  it  to 
an  abraded  surface,  and  relates,  rather  perhaps  as  a  coincidence 
than  as  a  proof,  his  own  experience  upon  this  subject. 

1761.  He  says,  "about  twenty  years  since,  while  examining 
some  vertebrae  containing  tubercles,  I  slightly  grazed  the  fore- 
finger of  the  left  hand,  by  a  stroke  of  the  saw.    The  scratch  was 
so  small  that  I  paid  no  attention  to  it ;  but  on  the  following  day 
it  was  slightly  inflamed,  and  there  gradually  formed  in  it,  and 
almost  without  pain,  a  small  round  tumour,  apparently  confined 
to  the  skin,  and  which  at  the  end  of  eight  days  was  of  the  size  of 
a  large  cherry-stone.     At  this  time  the  epidermis  cracked,  and 
showed  us  the  small  tumour  within,  which  was  yellow,  firm, 
and  in  every  respect  like  a  crude  yellow  tubercle.     I  cauterized 
it  with  the  deliquescent  hydro-chlorate  of  antimony,  and  felt  no 
pain  from  its  operation.    At  the  end  of  a  few  minutes,  however, 
after  the  fluid  had  penetrated  the  whole  substance  of  the  tumour, 
I  detached  it  by  a  gentle  pressure.     The  caustic  had  softened  it, 
and  made  it  exactly  like  a  soft  friable  tubercle.    The  walls  of  the 
cavity  which  had  contained  this  body,  were  of  a  pearl-gray  co- 
lour, slightly  semitransparent,  and  without  any  redness.     I  ap- 
plied the  caustic  afresh  to  these ;  the  parts  soon  healed,  and  I 
have  since  found  no  further  effects  from  the  accident."  p.  331. 

1762.  We  cannot,  however,  look  upon  this  case  as  a  positive 
propagation  of  the  tubercle  by  innoculation,  though  we  do  not 
in  the  slightest  degree  question  the  truth  of  the  statement;  for 
opportunities  for  their  multiplication  occur  in  every  phthisical 
patient,  by  the  passing  of  the  matter  of  tubercle  over  the  often- 
times denuded  bronchia  and  trachea ;  yet  it  is  very  rare  to  find 
tubercles  occupying  these  parts. 

*  Note  to  Laennec,  p.  330. 


PHTHISIS    PULMONALIS,  OR    CONSUMPTION.  523 


"  Of  Hereditary  Predisposition. " 

1763.  There  are  few  facts  better  established,  than  predisposi- 
tion from  hereditary  transmission,  in  certain  diseases  of  the  hu- 
man system;  among  these  the  consumptive  taint  perhaps  stands 
foremost.   We  have  had  frequent  opportunities  of  witnessing  the 
transmission  of  pulmonary  complaints;  and  in  a  few  instances, 
even  to  the  extinction  of  a  family.     One  of  this  kind,  was  re- 
markable for  the  extent,  and  the  uniformity  of  the  cause  of  death 
in  a  very  numerous  family.     This  predisposition  arose  on  the 
side  of  the  mother;  though  she  lived  herself  to  the  age  of  forty- 
three;  a  period  much  exceeding  that  of  any  of  her  children,  with 
the  exception  of  a  son,  who  died  in  his  forty-fifth  year.    This 
lady  bore  twenty-three  children,  without  being  able  to  suckle 
any  but  the  two  first.     The  males  much  exceeded  the  females 
in  number,  in  the  family;  yet  there  did  not  appear  to  be  any  ex- 
emption in  their  favour  in  the  transmission  of  the  phthisical  taint, 
except,  that  they  attained  in  general  a  greater  age  before  they 
died — some  died  about  puberty,  others  at  man,  or  womanhood; 
but  all,  with  the  exception  just  stated,  died  under  thirty.     The 
disease  in  no  instance  was  very  rapid;  they  generally  complained 
from  one  to  two  years  before  they  died.  But  what  was  remarka- 
ble in  the  history  of  this  family  was,  the  healthy,  nay  in  some 
instances,  the  athletic  appearance  of  the  men,  until  the  disease 
became  open  and  decided.     In  their  growth  and  stature,  they 
altogether  resembled  the  father ;  who  was  not  only  a  remarkably 
stout  man,  but  lived  beyond  the  eightieth  year.     The  females 
that  passed  puberty,  (two  in  number,)  were  rather  stout  women; 
while  the  mother  was  both  delicate  and  small. 

1764.  The  history  of  this  family  is  remarkable  in  another  par- 
ticular ;  it  lived  in  the  country,  was  very  wealthy,  and  always 
accustomed  to  the  various  physical  means,  that  is  so  generally 
found  successful,  in  either  destroying  the  predisposition,  or  in 
lessening  its  influence ;  yet  in  no  one  instance  in  this  family, 
was  this  successful,  though  the  open  form  of  the  disease  was  re- 
tarded perhaps  in  all.*  The  females  died  the  earliest.  But  this  is 

*  Dr.  Forbes,  (note  to  p.  332,)  says,  "  there  can  be  no  doubt  of  the  frequent- 
ly hereditary  character  of  consumption.  I  mention  this  circumstance  here* 
merely  with  a  view  of  enforcing:  the  vast  importance  of  keeping  this  in  sight 
in  the  physical  education  of  the  children  of  consumptive  parents.  The  pre- 
disposition cannot  be  avoided  in  such  cases;  but  no  sufficient  reason  seems  to 
exist  why  we  may  not  obviate  by  proper  management  their  actual  develop- 
ment, at  least  in  a  certain  proportion  of  cases."  Broussais  says  that  tuberclei 
are  very  often  developed  by  accidental  causes;  and  that  this  is  a  frequent  oc- 
currence in  the  army — here,  fatigue,  exposure,  or  other  circumstances,  may 
cause  the  appearance  of  phthisis,  even  in  such  as  might  never  have  had  this  to 


524  PHTHISIS    PULMONALIS,  OR   CONSUMPTION. 

an  extreme  case;  in  general,  the  tendency  to  consumption  is  not 
so  extensive;  visiting  only  certain  members  of  the  family,  while 
other  portions  escape;  and  this  oftentimes  without  any  obvious 
reason  for  the  selection,  or  the  exemption. 

1765.  On  the  other  hand,  we  sometimes  find  large  families  of 
children  destroyed  by  consumption,  without  our  being  able  to 
trace  it  to  hereditary  predisposition.     Laennec  mentions  an  in- 
stance he  himself  knew,  "in  which  the  father  and  mother  died 
upwards  of  eighty  years  of  age,  and  of  acute  diseases,  after  hav- 
ing seen  fourteen  children,  (born  healthy,  and  without  any  seem- 
ing predisposition  to  the  disease,)  successively  carried  off  by 
consumption,  between  the  ages  of  fifteen  and  thirty-five.     One 
other  child,  who  was  delicate  from  birth,  and  with  decided  marks 
of  tuberculous  predisposition,  is  however  still  living,  at  the  age 
of  forty-eight,  after  having  suffered  several  severe  attacks  of 
haemoptysis,  and  appeared  to  be  more  than  once  affected  with 
phthisis."  p.  332. 

1766.  He  adds,  "the  ancients,  and  especially  Aretaeus,  have 
carefully  described  this  particular  temperament  or  constitution. 
It  is  distinguished  by  the  brilliant  whiteness  of  the  skin,  the 
bright  red  of  the  cheeks,  the  narrowness  of  the  chest,  the  pro- 
jecting or  winged  configuration  of  the  scapulae,  and  the  slender- 
ness  of  the  limbs  and  trunk,  which  is  however  combined  with  a 
certain  degree  of  adipose  and  lymphatic  stoutness.  This  particu- 
lar constitution  is  attributed  by  Aretaeus  rather  to  haemoptysical 
than  consumptive  subjects ;  and  the  remark  is  worthy  of  that  ac- 
curate and  clever  observer,  as  there  can  be  no  doubt  that  phthi- 
sical subjects  possessing  this  configuration,  are  more  subject  to 
haemoptysis  than  others."  p.  331. 

1767.  The  period  of  life  at  which  phthisis  makes  its  appear- 

take  place,  but  for  this  fortuitous  exciting  cause. — Phleg.  Chron.  Vol.  II. 
p.  25. 

To  effect  the  object  suggested  in  Dr.  F.'s  note,  is  every  way  "devoutly  to 
be  wished" — but  how  is  it  to  be  accomplished?  We  regret  that  this  judicious 
writer,  has  not  offered  his  views  upon  this  subject;  for  but  one  mode  suggests 
itself  to  our  mind;  which  is,  the  gradual  development  of  all  the  physical  pow- 
ers of  the  body,  by  a  strict  observance  of  every  thing  that  relates,  to  what  is, 
(absurdly,)  called,  the  non-naturals;  but  even  this  should  be  under  the  direc- 
tion of  a  skilful  master.  The  first  perhaps  in  importance  among  these,  is  well- 
regulated  and  appropriate  exercises — and  for  this  purpose,  a  properly  con- 
ducted gymnasium  is  the  best.  We  are  persuaded,  we  have  seen  important, 
as  well  as  permanent  benefit  derived,  from  this  delightful  school  of  exercises; 
and  we  think  in  one  instance,  the  development  of  phthisis  was  prevented. 

Dr.  Baron  observes  upon  this  subject,  (Illustrations  of  the  Enquiry,  &c.  p. 
215,)  "since  it  appears  that  whatever  enfeebles  the  frame  or  deteriorates  the 
constitution,  predisposes  to  the  disease  in  question;  how  shall  we  avert  this  pre- 
disposition? The  answer  is  apparent;  we  must  do  every  thing  in  our  power  to 
invigorate  and  fortify  the  frame;  to  bring  all  its  functions  into  a  healthy  state; 
and  by  all  means  to  keep  them  so." 


PHTHISIS    PULMONALIS,    OR    CONSUMPTION.  525 

ance,  must  necessarily  be  subject  to  various  contingencies ;  and 
which  will  of  course,  either  hasten  or  retard  its  development, 
and  consequently  unsettle  the  precise  period  of  its  attack.  Thus, 
the  general  state  of  the  constitution ;  the  liability  to  the  action  of 
exciting  causes ;  and  force  of  these,  or  the  frequency  of  their  ap- 
plication, will  contribute  to  render  uncertain,  the  exact  time  of 
life  for  phthisis  to  make  its  appearance.  To  determine  therefore, 
any  tolerable  average  of  period,  will  require  the  mean  of  very 
many  cases — the  older  writers,  and  especially  Hippocrates,  fixed 
the  time  between  the  age  of  eighteen  and  thirty-five ;  and  it  is 
generally  conceded  he  was  nearly  right.  While  Bayle,  who  had 
charge  of  a  hospital  in  Paris,  determines  the  period  to  be  from 
the  fortieth  to  the  fiftieth  year. 

1768.  But  from  this  disease,  as  Laennec  justly  observes,  "no 
age  is  free."     "The  unborn  foetus  has  been  found  affected  with 
it."     It  is  extremely  common  among  the  children  of  the  com- 
mon people ;  it  is  likewise  frequent  in  old  age. 

1769.  Women  are  more  subject  to  phthisis  than  men.    Louis 
says,  "  des  cent  vingt-trois  cas  dont  il  s'agit,  soixante-dix  ap- 
partiennent  aux  femmes,  et  cinquante-sept  aux  hommes;"*  and 
this  opinion  is  confirmed  by  almost  all  the  writers  upon  the  sub- 
ject, and  is  in  strict  conformity  with  our  own  experience. 

"  Of  the  Physical  Signs  of  Ticbercles." 

1770.  As  no  attempt  had  been  made  to  ascertain  the  existence 
of  tubercles  in  the  lungs,  if  we  except  the  "percussion"  of  Aven- 
brugger,  before  the  discovery  of  the  stethoscope  by  Laennec ; 
and  as  he  is  now  looked  upon  as  the  highest  authority  upon  this 
subject,  by  the  profession  at  large,  we  shall  condense  what  this 
sagacious  physician  has  said  upon  it,  nor  offer  an  apology  for  its 
introduction,  as  we  are  satisfied,  that  we  are  performing  an  im- 
portant service  to  our  readers,  and  shall  trust  confidently  to  their 
good  feelings,  for  its  being  an  acceptable  one. 

1771.  Tubercles,  with  some  rare  exceptions,  commence  in  the 
summit  of  the  lungs.     The  earliest  signs  are  discoverable  below 
the  clavicle.     If  they  are  small  and  detached,  they  cannot  be 
discovered — at  this  time  the  health  appears  good ;  at  least  the 
cough  is  so  slight,  that  it  is  for  the  most  part  disregarded. 

1772.  But  when  there  is  an  accumulation  of  crude  or  miliary 
tubercles  in  the  upper  portion  of  the  lung,  the  sound  from  the 
percussion  of  the  clavicles  diminish,  and  is  usually  unequal;  this 
extends  sometimes  as  low  as  the  fourth  rib.  Dr.  Forbes  remarks 
on  this  observation,  that  "  in  no  case  is  the  importance  of  per- 

*  Recherches,  &c.  p.  522. 


526  PHTHISIS    PULMONALIS,    OR    CONSUMPTION. 

cussion  so  frequently  and  strikingly  evinced  as  in  the  early 
stages  of  phthisis.  A  single  blow  upon  the  clavicle  will  often 
afford  the  means  of  a  more  certain  diagnosis  and  prognosis  than 
weeks,  or  even  months  of  observation  on  the  general  symptoms." 
p.  334. 

1773.  No  other  parts  of  the  chest  will  give  rise  to  this  pheno- 
menon from  the  accumulation  of  tubercles,  except  the  intersca- 
pular  region,  where  there  may  be  at  the  root  of  the  lungs,  a  great 
number  of  them.  When  this  sign  exists,  and  even  when  absent, 
a  diffused  broncophonism  is  perceived  below  the  clavicle,  over 
the  infra-spinal  fossa  of  the  scapula,  and  in  the  axilla. 

Signs  of  the  Softening  of  Tubercles. 

1774.  When  the  tubercles  begin  to  soften,  the  same  signs  con- 
tinue; coughing  now  gives  rise  to  a  kind  of  guggling,  as  if  the 
matter  were  thick.     This,  however,  soon  becomes  more  like  the 
mucous  rattle  ;  the  cavernous  cough  indicating  pulmonary  exca- 
vation.    As  this  empties  itself,  the  respiration  also  becomes  ca- 
vernous; and  with  the  cough,  indicates  the  increasing  of  the 
cavity.  Broncophonism  is  succeeded  by  pectoriloquism.    Some- 
times as  the  excavation  empties  itself,  the  resonance  becomes 
clearer;  this  has  led  to  the  supposition  that  the  patient  was  im- 
proving, but  this  is  a  mistake.  At  the  time  the  tuberculous  mat- 
ter is  softening,  percussion  produces  a  guggling,  or  jar,  like  that 
yielded  by  a  cracked  pot,  with  a  peculiar  resonance,  declaring 
the  presence  of  a  cavity.  This  sign  determines,  that  the  excava- 
tion is  very  near  the  surface  of  the  lung,  but  is  only  to  be  ob- 
served in  thin  subjects.     When  one  of  these  superficial  excava- 
tions has  its  walls  thin,  soft,  and  not  adhering  to  the  costal  pleura, 
the  auricular  puff  frequently  accompanies  the  cavernous  respira- 
tion and  cough,  as  well  as  the  pectoriloquism.  In  this  case,  every 
word  is  followed  by  a  puff,  like  that  used  in  blowing  out  a  can- 
dle, and  "  would  be  mistaken  for  a  puff  in  reality,  if  the  sense  of 
touch  did  not  rectify  that  of  hearing." 

Signs  of  the  Complete  Discharge  of  the  Tuberculous  Matter. 

1775.  When  a  tuberculous  excavation  is  completely  empty, 
it  is  indicated  by  the  cavernous  respiration  and  cough.    The  ca- 
vernous rattle  is  no  longer  heard ;  or  only  temporarily,  if  secre- 
tion be  going  on  ;  but  will  disappear  for  hours  after  the  patient 
has  expectorated.     Now,  and  sometimes  before,  pectoriloquism 
becomes  perfect.  (See  par.  1774.) 


PHTHISIS    PULMONALIS,    Oil    CONSUMPTION.  527 


Symptoms  and  Progress  of  Phthisis. 

1776.  There  are  few  diseases  in  which  so  much  uncertainty 
of  diagnosis  prevails,  as  in  phthisis.   We  have  already  remarked 
how  vague  the  statements  are,  (par.  1715,)  as  regards  the  fre- 
quency of  this  disease,  and  this  owing  to  the  difficulty  of  deter- 
mining its  existence,   by  the  common,  or  general  symptoms. 
Too  much  has  always  been  taken  for  granted,  as  regarded  the 
pathological  condition  of  the  lungs;  and  this  would  still  have  pre- 
vailed, had  not  so  much  pains  and  talent  been  bestowed  lately 
on  this  subject,  by  men,  whose  zeal  and  opportunities  have  ena- 
bled them  to  establish  with  certainty  the  morbid  changes  in  these 
organs,  and  which  it  is  now  agreed,  shall  be  called  phthisis.    As 
we  have  laid  it  down  to  be  a  well-ascertained  fact,  that  tubercles 
are  the  cause  of  this  disease;  or  in  other  words,  have  restricted 
the  term  phthisis,  to  the  effects  of  these  bodies,  it  will  necessa- 
rily follow,  as  their  development  is  gradual,  and  oftentimes  suc- 
cessive, that  the  initial  symptoms  produced  by  their  presence, 
will  be  different  from  the  more  advanced  and  final  stages  of  their 
development;  and  in  this,  in  great  measure,  consists  the  difficulty 
of  deciding  on  the  existence  of  tubercles,  from  the  symptoms 
they  primarily  create. 

1777.  For  as  there  are  so  many  causes  which  give  rise  to 
cough,  expectoration,  and  pain,  independently  of  tubercles,  one 
cause  or  condition  may  readily  be  taken  for  another — in  either 
case  injury  may  arise,  as  indifference  or  over-anxiety  may  pre- 
vail.    With  a  view  to  prevent  either  of  these  errors,  we  will 
state  from  the  best  authorities,  as  well  as  from  our  own  expe- 
rience, all  that  is  at  present  known  of  the  diagnosis  of  consump- 
tion.    Laennec,  with  the  intention  of  lessening  the  embarrass- 
ments upon  this  subject,  has  considered  phthisis  under  five  dif- 
ferent forms  or  varieties,  and  as  there  appears  a  just  foundation 
for  this  division,  and  especially  as  it  comprehends  nearly  all  the 
symptoms  that  can  occur,  or  that  can  distinguish  one  state  of  the 
lungs  from  another,  we  shall  adopt  his  mode  of  treating  this  dif- 
ficult subject. 

1.  Regular  Manifest  Phthisis. 

1778.  This  frequently  begins  by  a  slight  dry  cough,  which 
may  continue  with  more  or  less  severity,  for  months,  or  even 
years.  Other  symptoms,  however,  generally  accompany  this 
condition;  such  as  an  abundant  expectoration  of  phlegm,  unea- 
siness about  the  chest,  and  sometimes  an  obscure  or  dull  pain, 


528  PHTHISIS    PULMONALIS,    OR   CONSUMPTION. 

which  we  have  often  seen  patients  attempt  to  relieve,  by  striking 
pretty  hard  upon  the  chest.  Should  another  "  disease  now  carry 
off  the  patient,  his  lungs  will  be  crowded  with  very  small  tu- 
bercles/'* 

1779.  Sometimes  these  symptoms  attack  subjects  predisposed 
to  phthisis,  and  apparently  in  their  best  health;  and  with  such  as 
may  have  a  hereditary  taint,  it  always  creates  uneasiness  and  dis- 
trust ;  so  much  so  is  this  the  case  sometimes,  that  the  patient  al- 
most falls  a  sacrifice  to  the  influence  of  depressing  passions,  or 
has  too  often  recourse  to  the  thousand  "  specifics  for  consump- 
tion," with  the  no  less  certain,  but  oftentimes  more  speedy  de- 
struction of  his  health.     Spitting  of  blood,  sometimes,  is  among 
the  very  first  threatenings  of  this  disease;  but  this  is  not  con- 
stant. Nor  does  it  always  prove  the  presence  of  tubercles,  though 
its  returns  may  be  both  frequent  and  severe. 

1780.  This  symptom,  however,  is  no  less  suspicious  than 
alarming;  and  should  neither  be  treated  with  undeserving  neglect, 
nor  with  undue  attention;  for  on  the  one  hand,  we  have  known 
it  to  take  its  unrestrained  course  to  a  fatal  issue ;  and  on  the 
other,  we  have  seen  the  patient  subjected  to  an  unnecessary,  in- 
jurious, and  severe  discipline.     The  latter  was  particularly  so, 
in  our  own  case,  as  will    be  mentioned   under  the  head  hae- 
moptysis.    If  other  symptoms  accompany  the  spitting  of  blood, 
which  are  known  also  to  belong  to  phthisis,  it  should  be  regard- 
ed as  but  too  certain  a  sign  that  the  lungs  are  infested  with  tu- 
bercles. 

1781.  Laennec  says,    "in  whatever  way  the  disease   com- 
mences, a  more  or  less  abundant  mucous  expectoration,  and  a 
constant  state  of  feverishness  gradually  supervene. ;>     The  latter, 
agreeably  to  our  own  observation,  is  by  no  means  constant;  for  we 
have  seen  patients  remain  free  from  all  febrile  excitement,  until 
the  expectoration  had  become  decidedly  purulent;  at  this  time, 
a  feverishness  would  manifest  itself,  and  would  sooner  or  later, 
and  with  more  or  less  intensity,  become  a  regular  and  confirmed 
hectic. 

1782.  We  are  disposed  to  agree  with  Broussais,  that  a  genu- 
ine hectic  fever  never  occurs,  until  the  tuberculous  matter,  or 
genuine  pus,  becomes  exposed  to  the  influence  of  atmospheric 
air:  and  that  as  soon  as  this  happens  in  the  lungs,  it  is  immedi- 
ately excited,  and  continues  until  death  closes  the  scene,  or  re- 
covery is  about  to  be  established,  (par.  1710,  case.)  This  fever  is 
the  never-failing  attendant  upon  phthisis,  when  accompanied  by 
purulent  sputa — we  say  when  attended  by  purulent  expectora- 

*  Laennec,  p.  345. 


PHTHISIS    FULMONALIS,    OR    CONSUMPTION.  529 

tion,  for  this  does  not  always  take  place,  though  the  patient  die 
of  the  disease.* 

1783.  This  fever  is  not  always  regular  in  its  phenomena;  but 
it  generally  has  two  periods  of  exacerbation;  namely,  one  about 
noon,  and  the  other  during  some  period  of  the  night.  It  i» 
sometimes  accompariied  manifestly  by  a  chill ;  and  occasionally 
observes  a  regular  tertian  type;  but  this  for  the  most  part  is 
slight;  and  never,  as  far  as  we  have  observed,  is  the  system  de- 
pressed to  a  state  of  danger  in  this  fever,  as  in  the  intermittent 
fever,  properly  so  called.  But  be  the  chill  ever  so  slight,  it  is 
followed  nearly  constantly  by  a  hot  stage,  which  eventually  ter- 
minates towards  morning  in  a  deluging  escape  of  perspiration. 
The  pulse  in  this  fever  presents  to  the  touch  peculiarities  as  re- 
,gards  its  frequency,  volume,  and  quickness,  that  is  perhaps  never 
found  in  any  other  fever,  and  it  may  therefore  bear  with  much 
propriety  the  specific  name  of  the  "  hectic  pulse." 

17S4.  As  regards  frequency,  it  is  rarely,  or  never  below  120 
strokes  in  a  minute,  and  oftentimes  this  is  exceeded;  its  volume 
is  always  small  or  attenuated,  and  its  quickness  remarkable  and 
decided.  There  is  another  peculiarity  belonging  to  this  consum- 
ing fever;  namely,  let  its  intensity  be  what  it  may,  it  is  never, 
as  far  as  we  have  seen,  attended  by  the  graver  symptoms  of  other 
fevers.  The  head  moreover  is  almost  sure  to  be  free  from  pain; 
and  the  intellectual  faculties  exempt  from  delirium.  The  respi- 

*  Louis,  (Recherches  sur  la  phthisic,  p.  402,)  however  gives  a  case  in  whkh 
the  pulse,  towards  the  close  of  the  disease,  became  very  much  accelerated, 
small,  and  weak;  though  their  was  "neither  cough,  nor  expectoration."  The 
dissection  however  renders  it  probable,  that  a  purulent  expectoration  had  ex- 
isted for  a  short  time  before  death,  though  it  may  have  escaped  even  the  vigi- 
lance of  Louis  himself.  For  a  considerable  time  before  death  there  was  a  small 
increase  of  the  natural  heat,  with  a  slight  acceleration  of  pulse;  and  a  chilliness 
took  place,  both  morning  and  evening.  This  most  probably  was  owing  to  the 
tubercles  being  about  to  develope  themselves,  and  though  not  capable  at  that 
moment  of  producing  a  genuine  hectic,  yet  were  sufficient  as  foreign  bodies, 
to  disturb  the  vascular  system  to  the  extent  just  stated.  But  as  the  disease 
was  about  to  come  to  a  fatal  close,  "the  heat  became  mere  or  less  considerable 
in  the  evening,  sometimes  preceded  by  chilliness,  and  always  followed  by 
sweats."  p.  403. 

The  dissection  is  detailed  as  follows;  "the  right  lung  adhered  closely  to  th'e 
costal  pleura  in  all  its  extent;  its  upper  lobes  swarmed  with  gray,  semitranspa- 
rent  granulations,  more  or  less  opaque  in  their  centre;  there  were  none  in  the 
inferior  portion.  The  left  lung  presented  feeble  cellular  attachments;  gray 
granulations  throughout  its  extent,  and  a  tuberculous  excavation  of  middle 
size  was  found  at  its  top;  this  was  lined  with  a  semi-cartilaginous  membrane, 
applied  to  the  healthy  parenchyma,  or  upon  the  granulations,  and  itself  co- 
vered by  a  buffy  exudation."  Now  we  cannot  comprehend  how  a  cavernous 
excavation  should  exist,  but  by  the  discharge  of  tuberculous  matter.  And  as 
but  one  was  found,  it  is  possible,  that  its  contents  may  have  been  expectorated 
without  its  having  been  observed;  and  if  this  be  so,  it  will  not  interfere  with 
the  position  just  stated  in  the  text. 

67 


530  PHTHISIS    PULMONALIS,    OR    CONSUMPTION. 

ration  is  sometimes  as  free  as  in  health  ;  the  digestive  organ  pre- 
serves its  power;  while  the  muscles  retain  their  strength  to  a  cer- 
tain extent,  however  extreme  the  emaciation  may  be. 

1785.  Diarrhoea  accompanies,  and  sometimes  seems  really  to 
alternate  with  the  night  sweats ;  this  is  occasioned,  agreeably  to 
Broussais,  Laennec,  and  others,  by  a  secondary  eruption  of  tu- 
bercles in  the  intestinal  tunics.     Broussais  says  it  is  frequently 
attended  by  ulcerations  in  the  intestinal  tube;  in  this  Laennec 
appears  to  agree;  at  least  he  says,  it  sometimes  happens  without 
either  inflammation  or  ulceration.     This  additional  evil  contri- 
butes largely  to  the  waste  of  the  patient's  strength;  and  but  too 
certainly  hastens  the  fatal  issue. 

1786.  In  females  the  catamenia  are  wont  to  disappear  very 
soon  after  hectic  manifests  itself;  and  sometimes  even  before  any 
severe  pulmonary  symptoms  show  themselves.     When  this  sup- 
pression takes  place,  it  is  almost  constantly  believed  to  be  the 
cause  of  the  disease;  and  too  often,  stimulating  and  active  medi- 
cines are  exhibited,  with  the  certain  effect  of  aggravating  the 
pulmonary  affection. 

1787.  It  were  every  way  desirable  that  this  point  should  be 
settled,  and  well  understood  by  the  young  practitioner;  as  in  this 
disease,  no  error  is  more  common  in  practice,  than  the  effect  be- 
ing taken  for  the  cause.     For  it  is  constantly  urged,  that  the 
phthisical  symptoms  when  they  show  themselves,  are  altogether 
dependent  upon  the  failure  of  the  catamenia,  and  that  remedies 
must  be  addressed  to  the  uterine  system,  to  restore  this  evacua- 
tion.    And  very  frequently,  as  just  observed,  this  belief  is  too 
exclusively  acted  upon ;  for  we  have  frequently  seen  the  most 
mischievous  consequences  follow  the  use  of  emmenagogue  me- 
dicines.  In  all  cases,  therefore,  where  we  have  reason  to  believe 
that  amenorrhoea  is  symptomatic  of  tubercles,  we  should  disre- 
gard this  symptom  altogether  in  our  prescriptions.* 

1788.  To  what  circumstance  is  this  suppression  owing?    it 
cannot  be  to  any  sympathy  between  the  lungs  and  the  uterine 
system;  for  it  does  not  take  place,  unless  as  a  mere  coincidence, 
in  any  of  the  more  violent  and  acute  diseases  of  the  lungs.     It 
cannot  be,  as  rs  generally  supposed,  from  debility;  as  this  is 
very  often  much  more  excessive,  yet  this  does  not  take  place. 
Nor  can  it  happen  from  febrile  excitement;  as  this  is  oftentimes 
more  exalted,  yet  no  stoppage  occurs. 

1789.  May  we  not  look  for  the  cause,  in  the  formation  of 
tubercles,  on  the  internal  face  of  the  uterus,  or  upon,  or  in  the 
ovaria?     Is  not  this  supposition    nearly  confirmed    by  Louis' 
thirty-second  case,  p.  401  ?    in  this  subject   menstruation  had 

•  See  Treatise  on  the  Diseases  of  Females,  by  the  author,  Art.  Amenorrhcra. 


PHTHISIS    PULMONALIS,    OR    CONSUMPTION.  531 

ceased  for  three  months  previous  to  death.  On  examining  the 
uterus,  "  its  cavity,  and  the  superior  half  of  its  neck  were  of. a 
yellowish-white  colour,  with  a  dull  and  unequal  surface,  which 
arose  from  their  superficial  coat  being  converted  into  a  very  firm 
tuberculous  matter,  about  a  line  in  thickness.  The  rest  of  the 
uterus  was  sound."  p.  405.  Now,  Louis  supposes,  that  in  this 
case,  the  tuberculous  development  probably  did  not  take  place, 
until  about  the  period  of  the  suppression  of  the  catamenia.  p* 
140.  And  he  remarks,  that  he  never  found  tuberculous  matter 
but  in  the  uteri  of  those  who  died  of  phthisis.  These  patholo- 
gical facts  are  highly  valuable  in  a  practical  point  of  view,  as 
they  prove  to  us  how  utterly  unavailing  must  be  every  means 
purporting  to  be  for  the  restoration  of  the  menstrual  discharge; 
and  they,  consequently,  tacitly  forbid  the  attempt.  How  far 
this  pathological  condition  may  be  of  general  occurrence,  remains 
to  be  proved;  but  what  little  is  known,  should  elicit  further  ob- 
servation ;  for  should  this  be  found  common,  when  the  catame- 
nia are  stopped,  it  may  become  a  useful  point  of  diagnosis,  and 
might  render  treatment  more  availing  than  at  present,  because 
not  absolutely  hopeless  when  it  does  not  take  place,  in  affections 
of  the  lungs  notarising  from  tubercles;  or  in  chronic  bronchitis 
similating  phthisis,  in  other  respects. 

1790.  Bayle  also  relates  a  case,  (Obs.  1st,)  in  which  the  cata- 
menia were  suddenly  suppressed,  as  was  supposed,  by  a  fright ; 
the  uterus  was  found  sound  though  her  lungs  were  tuberculated ; 
but  both  ovaria  "  presented  hard  unequal  tumours  of  a  blackish- 
red  colour  on  the  outside,  and  of  a  grayish-white  within,  pre- 
senting a  granular  suppuration;  the  ulceration  was  even  visible 
upon  a  part  of  the  external  surface."  (p.  138.)    In  this  case,  the 
ovaries  were  the  seat  of  the  tuberculous  affection ;  yet  the  sup- 
pression of  the  catamenia  was  sudden  and  attributed  to  fright; 
but  the  morbid  condition  of  the  ovaria  will  sufficiently  account 
for  the  interruption  of  the  menses,  without  calling  in  the  agency 
of  fear;  as  these  bodies  are,  we  believe,  the  remote  cause  of  this 
evacuation.     It  is  to  be  lamented,  that  neither  Laennec  nor 
Bayle,  has  been  as  attentive  to  the  condition  of  the  uterine"  sys- 
tem, as  the  subject  appears  to  demand;  Bayle  mentions  one  case, 
(as  just  related,)  in  which  he  carried  his  researches  to  the  uterus, 
but  Laennec  gives  not  even  one. 

1791.  No  sooner  does  hectic  fever  establish  itself,  than  emacia- 
tion takes  place  rapidly,  even  to  complete  marasmus.     "The 
nose  becomes  sharp  and  drawn;  the  cheeks  red  and  prominent; 
the  conjunctiva  of  the  eyes  is  of  a  shining  white,  or  with  a  shade 
of  pearl-blue ;  the  cheeks  are  hollow;  the  lips  are  retracted,  and 
seem  moulded  into  a  bitter  smile ;  the  neck  is  oblique,  and  im- 
peded in  its  movements,  the  shoulder  blades  are  projecting  and 


532  PHTHISIS    PULMONALIS,    OR    CONSUMPTION. 

winged;  the  ribs  become  prominent,  and  the  intercostal  spaces 
sink  in,  particularly  upon  the  upper  and  fore-parts  of  the  chest."* 

1792.  After  hectic  fever  and  expectoration  have  supervened, 
the  disease  varies  but  little  in  its  fatal  progress.     Laennec  says, 
that  hemoptysis  is  not  common  at  this  period  of  the  disease; 
but  we  have  certainly  seen  it  occur  frequently  at  this  time.     Oc- 
casionally however,  there  are  but  a  few  streaks  of  blood  in  the 
expectorated  matter.     Should  the  stethoscope  at,  this  period  in- 
dicate a  complete  evacuation  of  a  tuberculous  cavity,  a  great  im- 
provement of  symptoms  sometimes  takes  place,  which  leads  to 
the  belief,  that  a  solid  improvement  is  about  to  take  place.    This 
false  convalescence,  as  Laennec  terms  it,  may  last  for  days  or 
weeks ;  or  may  even  extend  to  months ;  of  which  he  relates, 
(p.  318,)  a  remarkable  instance. 

1793.  In  those  cases  in  which  the  amendment  just  mentioned 
takes  place,  and  which  lasts  for  several  months,  are  those  in 
which  the  secondary  eruption  does  not  take  place  until  after  the 
entire  softening  of  the  first  crop  of  tubercles.     But  the  cases  in 
which  the  cure  is  complete,  are  those  in  which  no  secondary 
eruption  takes  place. 

1794.  The  stethoscope  alone  detects  the  softening  of  the  tu- 
berculous matter,  and  its  subsequent  discharge  into  the  bronchia; 
the  local  symptoms  rarely  affords  any  assistance.     In  some  cases 
the  patient  himself  is  sensible  of  the  guggling  of  the  softened 
tubercle. 

1795.  "Notwithstanding  the  efforts  which  have  been  made, 
in  all  ages,  to  deduce  pathognomonic  signs,  from  the  appearance 
of  the  expectorated  matter  in  phthisis,  it  must  be  confessed  that 
this  affords  no  peculiar  characters  which  are  not  met  with  in 
chronic  catarrh.     And  modern  chemistry  has  thrown  no  light 
on  the  subject.     Three  different  kinds  of  matter  may  enter  into 
the  composition  of  the  sputa  of  consumptive  subjects,  viz.:  ca- 
tarrhal  mucus — the  matter  of  tubercles,  more  or  less  softened — 
and,  (sometimes,)  the  pus  secreted  by  tuberculous  excavations 
which  are  completely  empty.     Neither  chemical  analysis,  nor 
the  physical  characters  of  these  matters,  enable  us  certainly  to 
discriminate  one  from  the  other."     "It  is  extremely  rare  to 
meet  with  well-marked  tuberculous  matter  in  the  expectoration. 
When  this  is  completely  softened  it  combines  so  intimately  with 
the  puriform  mucus  secreted  by  the  bronchia,  that  it  is  impossi- 
ble to  distinguish  the  one  from  the  other.     Besides,  tuberculous 
matter  can  only  form  a  very  small  proportion  of  the  expectora- 
tion when  this  is  considerable.     If  it  amounts  to  more  than  a 
pound  daily,  considering  how  slowly  the  excavations  empty 

*  Laennec,  p.  347. 


PHTHISIS   PULMONALIS,    OR    CONSUMPTION.  533 

themselves,  we  cannot  believe  that  the  tuberculous  matter  can 
amount  to  more  than  twenty  grains — that  is,  to  a  thousandth  part 
of  the  whole."  "We  cannot  therefore  yield  much  confidence  to 
the  inspection  of  the  sputa  in  this  disease,  inasmuch  as  those 
which  are  most  characteristic,  viz.:  the  ash-coloured,  puriform 
and  vermicular,  are  frequently  met  with  in  chronic  catarrh."* 

1796.  Dr.  Forbes  thinks  Laennec  has  not  done  sufficient  jus- 
tice to  the  sputa,  as  a  sign  of  tubercles  in  the  lungs;  more  es- 
pecially in  the  latter  stages.     He  thinks  that  all  the  characters 
of  phthisical  sputa  may  be  found  in  chronic  catarrh  or  bronchitis, 
but  that  it  is  extremely  rare.  As  regards  ourselves  we  are  willing 
to  confess,  that  the  sputa  has  rarely  afforded  us  any  valuable  or 
certain  evidence  of  the  condition  of  the  pulmonary  tissue;  yet 
we  are  free  to  acknowledge,  that  our  frequent  disappointments 
have  rendered  us  rather  careless  oftentimes  in  our  examinations. 
Nor  will  we  positively  deny  but  that  a  very  repeated  and  close 
observance  of  the  physical  properties  of  the  sputa,  may  from 
long  habit,  lead  to  a  correct  estimate  of  their  nature.   And  as  we 
would  not  willingly  withhold  any  apparently  important  circum- 
stance connected  with  our  subject,  we  will  give  Dr.  Forbes'  con- 
densed but  ample  history  of  expectoration  in  phthisis,  derived 
from  various  and  best  accredited  sources,  and  especially  from  the 
latest  French  authorities. 

1797.  "  It  may  be  of  some  use  to  the  student  if  I  state  here 
in  a  few  words,  what  appears  to  me  the  most  usual  characters 
and  progressive  changes  of  the  expectoration  in  phthisis.    In  the 
earliest  stage  of  the  disease,  the  cough  is  dry,  or  attended  by  a 
mere  watery  or  slightly  viscid,  frothy  and  colourless  fluid ;  this, 
on  the  approach  of  the  second  stage  gradually  changes  into  an 
opaque,  greenish,  thicker  fluid,  intermixed  with  small  lines  or 
fine  streaks  of  a  yellow  colour.     At  this  period  also,  the  sputa 
are  sometimes  intermixed  with  small  specks  of  a  dead-white 
or  slightly  yellow  colour,  varying  from  the  size  of  a  pin's  head 
to  that  of  a  grain  of  rice,  and  which  have  been  compared  by 
Bayle  to  this  grain  when  boiled.     These  have  been  noticed  by 
many  writers  from  Hippocrates  downwards.  After  the  complete 
evacuation  of  the  tubercles,  the  expectoration  puts  on  many  forms 
of  purulency ;  but  frequently  assumes  one  particular  character, 
which  has  always  appeared  to  metobepathognomonic  of  phthisis, 
although  the  more  accurate  and  extensive  observations  of  modern 
pathologists,  has  proved  the  same  to  exist  occasionally  in  simple 
catarrh.     The  expectoration  to  which  I  allude,  consists  of  a  se- 
ries of  globular  masses,  of  a  whitish-yellow  colour,  with  a  rag- 
ged, woolly  surface,  and  somewhat  like  little  rolled  balls  of  cot- 


•  Laennec,  pp.  349,  350,  351. 


534  PHTHISIS    PULMONALIS,    OR    CONSUMPTION. 

ton  or  wool.  These  commonly,  but  not  always  sink  in  water. 
This  kind  of  expectoration  has  appeared  to  me  most  eommon  in 
young  subjects,  of  a  strongly-marked  strumous  habit  and  in  whom 
the  disease  was  hereditary.  At  other  times,  in  the  cases  in  which 
these  globular  masses  are  observed,  and  also  in  those  in  which 
they  have  not  appeared,  the  expectoration  puts  on  the  common 
characters  of  the  pus  of  an  abscess,  constituting  an  uniform, 
smooth,  coherent,  or  diffluent  mass,  of  a  greenish,  or  rather  a 
grayish  hue,  with  an  occasional  tinge  of  red,  (from  intermixed 
blood,)  and  sometimes  more  or  less  fetid.  This  is  the  'sputum 
cinereum  et  csenosum,  argillae  cujusdam  liquidioris  speciem  prae 
se  ferens'  of  Bennet."* 

1798.  The  symptoms  which  we  have  described  as  accompa- 
nying manifest  phthisis,  cannot  be  considered,  even  when  united 
in  the  same  subject,  according  to  Laennec,  as  certain  signs  of 
the  existence  of  tubercles  in  the  lungs,  as  a  simple  catarrh  may 
produce  the  same  signs.     For  he  declares  he  attended  a  young 
woman  who  died  with  all  the  symptoms  of  phthisis,  whose  lungs 
were  found  on  dissection  to  be  perfectly  sound,  and  in  whom  no 
organic  lesion  could  be  found,  with  the  exception  of  the  liver. 

1799.  Bayle's  48th  and  49th  cases  were  of  a  similar  kind. 
The  first  of  these  patients  "  was  subject  to  frequent  colds,  which 
lasted  many  months  together  in  the  winter."   "He  experienced 
deep-seated  pains  in  the  chest,  and  his  cough  was  much  stronger 
than  ordinary."     "The  pulse  was  small,  frequent,  and  rather 
irregular.     At  the  same  time  there  was  heat  of  the  skin,  night 
sweats,  slight  delirium,  frequent  cough,  and  a  slight  diarrhoea ; 
very  abundant  expectoration  of  an  opaque,  yellowish  and  green- 
ish-white, quite  like  purulent  matter.   Respiration  short,  frequent, 
laborious;  slight  rattling;  tongue  white  in  the  middle,  very  red 
at  the  edges;  thorax  sounding  well  throughout."  p.  433. 

1800.  "The  two  lungs  adhered  to  the  surrounding  parts  by 
means  of  cellular  layers;  they  were  both  soft  and  very  crepitant, 
though  their  tissue  appeared  a  little  red  when  cut  into.     There 
was  neither  tubercle  nor  hardness  in  any  place.     The  mucous 
membrane  was  rather  red,  and  a  little  thickened  in  the  trachea; 
it  was  still  more  so  in  the  bronchiae  and  the  bronchial  ramifica- 
tions; and  the  redness  was  the  more  marked  the  further  one  pur- 
sued the  subdivisions  of  these  ramifications.     One  saw  through- 
out these  bronchial  pipes,  a  matter  resembling  that  the  subject 
had  expectorated  during  life;  and  it  was  only  after  having  scraped 
this  matter,  that  one  saw  the  swelling  and  redness  of  the  mucous 
membrane."  p.  435. 

1801.  In  the  seeond  case,  the  patient  had  complained  for 

•  Note  to  p.  352  of  Laennec. 


PHTHISIS  PULMONALIS,   OR    CONSUMPTION.  535 

nearly  four  years  of  frequent  cough  and  mucous  expectoration, 
at  one  time  puriform,  at  another  transparent  and  ropy.  The 
cough  increased ;  the  sputa  were  opaque,  thick,  round,  of  a  yel- 
lowish-white, and  like  pus.  The  pulse  became  small,  feeble,  un- 
equal and  intermittent,  but  not  too  frequent.  After  some  time 
he  expectorated  mucous  sputa  quite  puriform,  and  had  a  conti- 
nued fever.  A  rattling  was  perceived  in  his  breathing;  never- 
theless the  chest  sounded  well  on  percussion.  The  rattling  last- 
ed two  days,  the  pulse  was  frequent,  the  cough  strong,  mucous 
sputa  very  abundant,  and  like  pus ;  in  a  few  days  he  died.  p. 
438,  439. 

1802.  On  opening  the  body  the  mucous  membrane  of  the 
trachea  and  of  the  bronchiae  appeared  in  a  sound  state.    A  puri- 
form mucus  was  every  where  to  be  seen  in  the  bronchial  tubes. 
The  lungs  were  soft,  crepitating,  and  perfectly  sound ;  there 
were  some  slight  adhesions  to  the  pleura;  and  the  cellular  layers 
which  formed  these  adhesions,  showed  marks  of  recent  inflam- 
mation, p.  440. 

1803.  These  cases  teach  us,  Laennec  says,  to  never  assert  po- 
sitively, that  the  disease  is  phthisis,  where  none  of  the  physical 
signs  are  present,  when  the  chest  is  examined  by  percussion  and 
auscultation.     In  confirmation  of  this  he  says,  "  in  the  course  of 
last  year,  I  several  times  met  MM.  Recamier  and  Richerahd  in 
consultation,  6*h  the  case  of  a  young  lady  who  seemed  already 
far  gone  in  consumption,  but  in  whom  I  constantly  affirmed  the 
lungs  to  be  sourd  from  the  absence  of  physical  signs  in  this  case. 
The  result  of  trie  dissection  confirmed  the  correctness  of  my 
diagnosis;  the  disease  was  schirrus  pancreas  complicated  with  a 
simple  catarrh."  p.  355.  These  cases  are  of  great  practical  value, 
as  they  determine  that  simple  catarrh,  unattended  by  an  organic 
lesion  of  the  lungs,  may  completely  similate  phthisis.  And  again, 
they  teach  us  that  the  exploration  of  the  chest  should  be  attend- 
ed to,  before  the  diagnosis  of  a  pulmonary  disease  is  pronounced, 
and  that  the  absence  of  the  phthisical  physical  signs  determine 
the  case  not  to  be  consumption  with  great  certainty. 

2.  "Irregular  Manifest  Phthisis" 

1804.  By  this  term  Laennec  wishes  to  designate  those  cases 
of  phthisis,  in  which  the  disease  seems  to  begin  in  some  other 
organ  besides  the  lungs.     It  is  frequently  found,  that  a  chronic 
form  of  diarrhoea  will  precede  the  local  and  general  symptoms 
of  phthisis.     In  such  cases,  dissection  reveals  ulcerations  and 
small  miliary  tubercles  in  the  intestines,  already  softened  and 
destroyed.     Perforation  of  the  intestines  sometimes  takes  place 
in  these  cases,  preceded  by  acute  peritonitis  and  peritoneal  tym- 


536  PHTHISIS    PULMONALIS,    OR    CONSUMPTION. 

pany;  this  condition  is  announced  by  the  general  symptoms  of 
peritonitis,  except  perhaps  that  the  onset  is  more  sudden  and  the 
pain  more  acute,  p.  355,  et  seq. 

3.  «  Latent  Phthisis." 

1S05.  This  form  is  rarely  latent  through  its  whole  course ;  but 
it  is  not  uncommon  that  the  characteristic  signs  do  not  show 
themselves  until  a  short  time  before  death,  and  the  disease  to 
have  been  mistaken  for  some  other  affection.  But  phthisis  is 
never  so  completely  masked  as  by  pulmonary  catarrh;  as  it  may 
have  all  the  prominent  symptoms  of  phthisis,  as  haemoptysis, 
hectic  fever,  emaciation,  and  an  expectoration  so  much  resem- 
bling it,  that  it  is  impossible  to  distinguish  it.  In  the  beginning, 
it  may  be  said  that  phthisis  is  generally  latent,  as  it  is  common 
to  find  miliary  tubercles  in  lungs  otherwise  healthy,  and  in  sub- 
jects that  had  never  shown  any  signs  of  consumption,  p.  358. 
Louis  and  Andral  also  mention  this  latent  form. 

4.  "rfcute  Phthisis." 

1806.  "  Under  this  term  are  included  those  cases  which,  after 
remaining  latent  for  a  longer  or  shorter  period,  at  length  unfold 
themselves  all  at  once,  with  acute  fever,  emaciation,  and  other 
symptoms  of  such  severity  as  to  carry  off  the  patient  at  the  end 
of  six  weeks,  a  month,  or  even  a  shorter  period."  p.  359. 

1807.  A  great  number  of  tuberculous  masses  or  separate  tu- 
bercles are  found  in  these  cases;  they  soften  at  one  and  the  same 
time;  or  a  second  crop,  of  great  extent,  is  found  advancing.     In 
these  cases,  the  patients  sink  under  the  violence  of  the  fever  thus 
suddenly  and  powerfully  excited.     Laennec  gives  a  case,  which 
terminated  in  less  than  a  month,   p.  359.     Louis,  p.  414,  also 
gives  one,  in  which  the  disease  continued  thirty-five  days,  and 
but  twenty-five  after  the  cough  showed  itself.     In  this  case  the 
lungs  were  found  adherent  in  some  places;  the  upper  lobe  con- 
tained a  considerable  number  of  gray  semitransparent  granula- 
tions, and  small  tuberculous  masses  not  yet  softened,  surrounded 
by  a  tissue  that  was  slightly  engorged.    The  right  lung  adhered 
universally  to  the  pleura,  and  was  completely  studded  with  tu- 
berculous matter,  for  two  inches  high  and  two  broad,  which  con- 
tained a  kind  of  canal  filled  with  a  thick  fluid,  the  colour  of  the 
lees  of  wine. 

5.  "  Chronic  Phthisis." 

1808.  Under  this  name  we  may  include  those  cases  which  may 


PHTHISIS    PULMONALIS,    OK    CONSUMPTION.  537 

last  five  or  six  years,  or  even  much  longer — marked  by  periods 
of  increase,  during  which  hectic  fever  is  manifest,  and  emacia- 
tion makes  rapid  progress;  and  by  remissions  of  longer  or  shorter 
duration,  and  these  sometimes  so  complete,  that  fever,  cough, 
and  expectoration  cease,  and  the  patient  recovers  his  flesh.  Cases 
of  this  kind,  as  must  appear  from  what  is  stated  above,  are  the 
consequence  of  successive  eruptions  of  tubercles,  usually  also  few 
in  number.  It  is  in  these  that  the  pulmonary  cicatrices  are  most 
commonly  found."  p.  360. 

Of  the  Treatment  of  Phthisis. 

1809.  On  this  subject,  what  can  we  say  that  will  encourage 
the  practitioner  to  perseverance,  or  tempt  the  patient  to  submis- 
sion? We  have  taken  much  pains  to  collect  the  opinions  of  some 
of  the  best  practical  authorities  upon  this  point,  and  lament  we 
are  obliged  to  declare,  that  we  have  gained  nothing  by  our  search; 
for  all  agree  in  the  incurable  nature  of  the  disease;  and  all  lament 
the  paucity  and  uncertainty  of  even  our  palliative  means.   In  de- 
claring phthisis  to  be  an  incurablp  disease,  we  may  at  first  sight 
appear  chargeable  with  inconsistency,  as  we  have  -admitted  this 
in  another  place,  (par.  1703,)  to  be  otherwise — but  this  is  not 
so  in  reality.     When  the  question  was  agitated,  "is  phthisis  a 
curable  disease?"  we  admitted  on  the  best  authorities,  that  cures 
took  place  sometimes,  even  after  the  most  formidable  symptoms 
had  made  their  appearance ;  but  that  these  cases  were  not  only 
rare,  but  were  effected  by  the  efforts  of  nature  alone.     We  then 
pointed  out  by  what  means  this  end  was  accomplished ;  and  we 
have  now  to  confess,  that  we  cannot  by  any  means  in  our  power 
imitate  the  example. 

1810.  We  have  had  experience  abundantly  ample,  to  test  the 
efficacy  of  almost  every  plan  hitherto  proposed  for  the  cure  of 
phthisis ;  and  we  lament  to  say,  that  the  powers  of  the  remedies 
recommended  for  its  cure,  have  been  we  fear  solely  confined  to 
the  hands  of  the  proposers.    But  we  say  this  with  the  most  per- 
fect good  will  towards  such  as  have  declared  their  success,  and 
have  generously  made  known  their  plans ;  though  we  have  the 
mortification  to  say,  that  so  far  no  one  of  them  has  ever  suc- 
ceeded in  our  hands.     And  we  fear  we  announce  too  solemn  a 
truism,  when  we  say  that  we  do  not  believe,  that  phthisis  pro- 
perly so  called,  has  ever  been  cured  by  art;  and  perhaps  no  better 
evidence  can  be  adduced  that  this  is  almost  the  universal  feeling 
on  this  subject,  than  the  numerous  "  infallible  remedies"  pro- 
posed for  its  cure.  For  were  tubercles  under  the  controul  of  any 
one  remedy,  that  remedy  would  be  every  way  ample  for  almost 

68 


5SS  PHTHISIS    PULM0NALIS,    OR    CONSUMPTION. 

every  case  that  could  occur — but  how  stands  the  fact?  Has  any 
one  means  in  the  vast  catalogue  of  remedies,  outlived  its  hour, 
not  to  say  its  author?  It  would  be  time  ill  spent,  to  even  pass  in 
review  the  various  plans  purporting  to  be  cures  for  phthisis. 

1811.  Aware    of   the  total  insufficiency  of  every  remedial 
agent  heretofore  proposed,  Laennec  most  judiciously  passes  the 
much  greater  part  of  them  without  notice;  and  on  such  as  he  has 
thought  fit  to  mention,  because  they  were  at  one  time  popular, 
he  condemns  by  a  sweeping  disbelief  of  their  efficacy.   He  never- 
theless employs  his  great  experience  in  the  best  manner  he  is 
able,  by  pointing  out  the  most  natural  indications,  though  that 
experience  has  not  put  him  in  possession  of  the  power  to  fulfil 
them. 

1812.  He  says,  "  that  the  most  rational  indication  to  be  ful- 
filled as  soon  as  we  have  ascertained  the  existence  of  the  disease, 
is  to  prevent  the  secondary  eruption  of  tubercles ;  as  in  this 
case,  if  the  primary  tubercular  masses  were  not  extremely  large 
or  numerous,  which  they  very  seldom  are,  a  cure  would  neces- 
sarily take  place  after  they  are  softened  and  evacuated."  p.  361. 

1813.  "The  second  indication  should  be,  to  promote  the  soft- 
ening and  evacuation  or  absorption  of  the  existing  crop  of  tuber- 
cles.    Though  the  first  of  these  indications,  like  the  facts  on 
which  it  rests  is  new,  nevertheless,  all   the  means  which  have 
been  thought  best  calculated  to  fulfil  it  have  been  put  in  practice 
from  time  immemorial ;  it  having  always  been  the  common  en- 
deavour of  physicians  to  prevent  the  development  of  phthisis  in 
subjects  threatened  with  it,  either  from  constitutional  predispo- 
sition, or  from  the  actual  presence  of  unpleasant  symptoms.     In 
the  latter  class  of  cases,  the  mischief  is  already  done,  inasmuch 
as  the  first  symptoms,  general  and  local,  and  even  the  physical 
signs,  do  not  show  themselves  very  often  until  long  after  the 
formation  of  tubercles."  Ib. 

1814.  The  means  proposed  to  prevent  the  development  of 
tubercles,  are  first,  blood-letting.    This  remedj7  has  been  recom- 
mended in  several  different  ways ;  1,  in  small  quantity,  and  fre- 
quently repeated  ;  observing  to  diminish  the  quantity,  in  propor- 
tion to  the  frequency  ;  2,   in  larger  quantity,  so  as  to  make  a 
decided  impression  upon  the  system.   But  unfortunately,  neither 
of  these  plans  have  succeeded  in  the  object  for  which  they  were 
proposed.      It  now  seems  pretty  generally  admitted,   that  this 
remedy  should  never  be  employed,  except  in  such  cases  as  bear 
evidence  of  inflammation,  either  general  or  local.   We  have  cer- 
tainly seen  it  afford  much  relief  under  such  circumstances;  but 
to  be  of  no  advantage  under  any  other;  for  "bleeding  can  neither 
prevent  the  formation  of  tubercles,  nor  cure  them  when  form- 


PHTHISIS    PULMONALIS,    OK    CONSUMPTION.  539 

ed."  When  the  abstraction  of  blood  becomes  necessary  from 
the  presence  of  local  inflammation,  the  more  certain  relief  is  ob- 
tained by  leeches,  or  cupping  over  the  pained  part. 

1815.  Laennec  very  properly  condemns    the   more  violent 
means  recommended  ever  since  the  clays  of  Hippocrates  down- 
wards; as  the  actual  or  potential  cauteries,  by  saying  he  never 
in  a  single  instance  effected  a  cure,  though  he  employed  them. 
Moxa  has  not  proved  in  his  hands  more  successful  than  the  other 
escharotics;    nor  did  he  insist  upon  the  caustic  potass,   when 
his  patient  was  averse  to  it.     Our  own    experience    in    local 
and  irritating  remedies  to  the  chest,  but  too   certainly  confirms 
that  of  Laennec  ;  and  as  we  have  never  derived  any  permanent 
advantage  from  their  use  in  phthisis,  we  have  ceased  for  many 
years  to  employ  them;  thinking  with  Laennec  that  "  measures 
so  painful  ought  not  to  be  had  recourse  to,  unless  they  are  found 
by  experience  to  hold  out  a  reasonable  hope  of  success." 

1816.  Blisters,  issues,  setons,  tartarized  antimony  in  plaster, 
cautery  to  the  verge  of  the  anus,  &c.   should  all  be  held  under 
the  same  proscription. 

1817.  The  second  indication  is,  to  promote  the  softening  of 
the  tubercles.     This  has  been  attempted  by  a  vast  variety  of  re- 
medies, as  lime   water,  sulphurous   waters,  both   internally  and 
externally,  muriate  of  ammonia,  carbonates  of  ammonia,  soda, 
nitrate  of  potass,  hydrochlorate  of  soda,  hydrocyanic  acid,  iodine, 
&c.  &c.  each  of  which  have  been  lauded  and  contemned  in  its  turn; 
so  that  neither  holds  at  present,  the  smallest  rank  as  a  remedy 
for  phthisis.     The  iodine,  however,  seems  to  deserve  further 
trial,  as  its  influence  upon  glandular  derangements  is  undoubted; 
and  though  we  are  of  opinion,  that  the  analogy  between  such  af- 
fections and  tubercles  is  very  remote,  still,  as  this  substance  has 
been  found  useful  in  several  other  diseases   beside   bronchocele, 
it  may  be  fairly  entitled  to  further  trial.     Of  the  other  powerful 
remedy,  the  hydrocyanic  acid,  we  cannot  speak  a  word  in  its 
favour. 

1818.  Before  the  pathology  of  phthisis  was  ascertained,  it  was 
generally  supposed,  that  it  consisted  chiefly  in  ulcers  in  the  lungs; 
and  with  an  expectation  that  they  might  be  healed  by  the  same 
means,  that  were  in  common  use  for  this  purpose  on  the  external 
surface,  the  various  balsams  and  arornatics  were  liberally  exhi- 
bited— hence  arose  the  praises  of  the  balsams  of  Tolu,  Peru,  and 
Mecca  ;  turpentine,  camphor,  sulphur  dissolved  in  various  vola- 
tile oils,  all  of  which  are  now  deservedly  laid  aside.     With  the 
same  intention  various  gases  were  breathed  ;  and  with  a  similar 
hope,  the  vapours  of  rosin,  tar,  myrrh,  benzoin,  petroleum,  wax, 
&c.  were  inhaled,  which,  like  their  predecessors,  are  now  bu- 
ried "  in  the  tomb  of  all  the  Capulets."     And  when  either  of 


540  PHTHISIS    PUI-MONALIS,    OR    CONSUMPTION. 

these  substances  had  been  found  successful,  it  must  have  been 
in  simulated  phthisis,  as  chronic  catarfh  is  sometimes  wont  to 
do.  We  shall  not  notice  the  host  of  empirical  remedies  ;  as 
they  of  course  must  be  put  under  the  same  ban  as  those  al- 
ready proscribed. 

1819.  Laennec  says,    "of  all  the  measures  hitherto  recom- 
mended for  the  cure  of  phthisis,  none  has  been  followed  more 
frequently  by  a  suspension,  or  complete  cessation  of  the  disease, 
than  change  of  situation."     But  even  this  statement  must  be  re- 
ceived with  caution,  or  perhaps  with  distrust,  as  a  general  ad- 
mission, as  but  very  few  phthisical  patients  can  derive  advantage 
from  it;  since,  change  of  climate,  as  a  remedy  in  this  complaint, 
requires  a  peculiar  condition  of  the  lungs,  that  it  may  be  fol- 
lowed with  benefit.     And  while  upon  this  subject,  we  cannot 
lament  too  deeply,  the  unavailing,  nay,  in  some  instances,  the 
unfeeling  practice,  of  sending  invalids  of  this  kind  from  their 
comfortable  homes,  and  their  kind  friends,  to  die  in  a  strange 
land,  bereft  of  almost  every  solace  that  illness  and  suffering  so 
strongly  claim.     The  removal  to  a  temperate,  or  warm  climate, 
has  for  the  most  part  been  sadly  abused.    The  probability  of  ad- 
vantage, and  the  chances  against  it,  have  not  been  as  carefully 
weighed,  as  the  high  responsibility  attached  to  the  advice  has 
merited.     The  cases  in  which  this  change  might  be  useful,  have 
not  been  discriminated  with  sufficient  care  from  those  in  which 
it  would  be  altogether  unavailing,  if  not  mischievous.   For  these 
reasons  we  most  gladly  avail  ourselves  of  the  opinion  of  Dr. 
Clark  .upon  this  subject,  which  we  extract  from  a  note  of  Dr. 
Forbes,  in  his  translation  of  Laennec,  together  with  the  intro- 
ductory observations  of  the  latter  upon  the  competency  of  his 
friend,  to  give  the  best  possible  opinions  upon  this  important 
subject. 

1820.  "For  the  following  note  I  am  indebted  to  my  friend 
Dr.  Clark,  late  of  Rome,  but  now  resident  of  London  ;  whose 
opportunities  of  witnessing  the  influence  of  climate  in  consump- 
tion, have  been,  perhaps,  unequalled,   and  whose  accuracy  of 
observation,  and  soundness  of  judgment,  are,  at  least,  equal  to 
his  opportunities.     I  am  happy  to  say,  that  Dr.  Clark  is  at  this 
time  preparing  for  publication  a  work  on  the  Effect  of  Climate 
on  Consumption  and  other  Diseases,  which  I   doubt  not  will 
throw  great  light  on  the  subject  now  under  consideration." — 
Trans. 

1821.  "  I  consider  consumption,  with  your  distinguished  au- 
thor, as  a  disease  very  generally  consequent  to  a  deranged  or 
cachectic  state  of  the  system,  originating  in  a  series  of  func- 
tional disorders,  and  often  favoured  by  an  hereditary  predispo- 
sition to  tubercles.     When  adopted  for  the  removal  of  this  state 


PHTHISIS   PULMONALIS,    OR    CONSUMPTION.  541 

of  the  system,  and  previously  to  the  actual  development  of  tu- 
bercles in  the  lungs,  I  look  upon  change  to  a  milder  climate 
as  a  measure  of  the  utmost  importance,  and  likely,  when  well- 
timed,  and  combined  with  such  other  treatment  as  the  case  may 
require,  to  go  a  great  way  to  the  acquirement  of  this  desirable 
object.  If  the  mischief  has  advanced  a  little  further,  and  there 
are  good  reasons  for  believing  that  tubercles  are  already  formed 
in  the  lungs,  more  especially  if  a  disposition  to  inflammation  of 
the  organs,  or  to  haemoptysis,  has  manifested  itself;  then,  change 
of  climate  becomes  a  more  doubtful  measure ;  and,  unless  adopt- 
ed with  judgment,  and  with  some  precaution,  may  accelerate, 
rather  than  retard  the  progress  of  the  disease.  In  cases  of  this 
kind,  it  will  be  necessary,  previously  to  undertaking  the  jour- 
ney, to  remove,  or  at  least  to  moderate,  the  more  evident  or  im- 
portant of  the  functional  derangements,  to  subdue  excitement, 
and  diminish  plethora.  Much  evil  has  arisen  from  inattention 
to  these  precautions.  Medical  men  in  general  seem  hardly  suf- 
ficiently aware  of  the  great  excitement  produced  in  the-  system 
by  travelling,  and, of  the  necessity,  therefore,  of  removing  those 
morbid  complications  most  likely  to  suffer  aggravation  from 
this.  If  the  disease  has  made  still  greater  progress,  and  the 
cough,  expectoration,  emaciation,  hectic  fever,  and  the  results 
of  auscultation,  leave  no  doubt  of  the  advanced  stage  of  the 
tubercles ;  the  mischief  to  be  apprehended  from  the  exposure, 
the  fatigue,  the  irritation,  and  excitement  of  a  long  journey,  is 
greatly  increased  ;  and,  under  such  circumstances,  generally 
speaking,  no  advantage  is  to  be  expected  from  the  change ;  and 
very  often  the  fatal  termination  will  be  accelerated  by  it.  But 
should  the  symptoms  just  enumerated,  from  whatever  cause, 
have  become  much  mitigated,  and  more  especially  if  there  is  rea- 
son to  believe,  from  a  careful  examination  of  the  chest,  that  the 
disease  is  confined  to  a  small  portion  of  the  lungs ;  then  a  resi- 
dence in  a  milder  climate  affords  the  best  opportunity  of  aiding 
the  efforts  of  nature  in  the  work  of  reparation ;  and,  by  contri- 
buting to  the  reestablishment  of  the  general  health,  will  tend  to 
prevent  the  further  formation  of  tubercles." 

1822.  "A  change  of  climate  having  been  decided  on,  the  par- 
ticular situation  to  be  selected  becomes  a  question.  Professor  La- 
ennec's  decided  preference  of  a  maritime  residence  is  not,  perhaps, 
founded  on  a  very  extensive  experience;  certain  it  is,  however, 
that  as  well  in  this  country  as  on  the  continent,  the  places  chiefly 
frequented,  and  which  I  have  had  an  opportunity  of  observing, 
are  Hyeres  in  the  south  of  France,  Nice  in  Piedmont,  Pisa,  Rome 
and  Naples  in  Italy.  Each  of  these  places  may  have  some  advan- 
tages when  compared  with  others,  and  when  considered  in  re- 
ference to  each  individual  case.  The  constitution  of  the  patient, 


542  PHTHISIS    PULMONALIS,  OR   CONSUMPTION. 

the  coexistence  of  other  diseased  states  with  the  pulmonary  affec- 
tion, the  previous  abode  and  the  habits  of  the  patient,  &c.  &c. 
must  be  taken  into  account  in  fixing  the  decision.  In  almost 
every  case,  where  the  removal  to  a  milder  climate  can  be  con- 
veniently effected  by  sea,  this  means  is  much  preferable  to  a 
journey  by  land;  in  some  cases,  the  good  effects  produced  by  a 
voyage  are  very  remarkable." 

1823.  Notwithstanding  the  uncertainty  that  may  attend  change 
of  climate,  it  is  proper  that  we  should  not  altogether  lose  sight 
of  it  as  a  remedy,  and  especially  in  cases  of  phthisis  that  may 
have  been  casually  produced,  as  the  experiments  of  Flourens 
upon  birds,  demonstrate  an  agency  in  temperature,  that  is  strong- 
ly marked,  as  the  following  account  appears  to  prove. 

li  Action  of  Cold  on  the,  Lungs. — It  is  stated  in  our  esteemed 
cotemporary,  the  Journal  de  Medecine  Pratique  for  August 
last,  that  M.  Flourens  has  made  some  important  experiments 
relative  to  the  action  of  cold  upon  animals.  A.  young  bird  sud- 
denly exposed  to  a  great  and  continued  cold,  is  seized  with  so 
violent  an  oppression  of  the  chest,  as  to  become  instantly  motion- 
less, respires  with  extreme  pain,  ceases  to  eat  or  drink,  and  dies 
in  a  few  hours  with  acute  pneumonia.  In  this  case  the  lungs  on 
examination  appear  of  a  deep  red  colour,  and  are  gorged  with 
blood. 

"If,  on  the  contrary,  the  cold  is  increased  slowly,  and  with 
interruptions,  the  bird  is  affected  with  chronic  pulmonary  in- 
flammation, and  in  this  case  its  lungs  are  red  and  gorged  with 
blood  in  some  places,  and  in  a  state  of  suppuration  in  others. 

"  These  results  led  M.  F.  to  think  that  he  had  a  direct  method 
of  investigating  one  of  the  most  serious  diseases  with  which  man- 
kind are  afflicted,  pulmonary  consumption.  He  wished  to  ascer- 
tain, 1st,  whether  in  certain  given  cases,  cold  alone  sufficed  to 
produce  this  disease;  2d,  whether  in  these  same  cases  it  was  suf- 
ficient to  avoid  the  cold  in  order  to  escape  the  disease ;  3d,  finally, 
whether  this  disease  commenced  by  cold  could  not  be  cured  solely 
by  a  moderate  temperature. 

"With  this  view,  having  taken  a  number  of  pullets  of  the 
same  brood,  he  placed  some  in  a  place  constantly  preserved  of  a 
mild  temperature:  none  of  them  were  affected  with  phthisis  pul- 
monalis.  Some  of  them  were  exposed  to  all  the  variations  of  the 
weather;  almost  all  died  of  phthisis  pulmonalis,  after  having 
passed  through  all  the  degrees  of  consumption.  Finally,  others, 
after  having  been  exposed  like  the  preceding  to  all  the  atmos- 
pheric variations,  and  after  having  shown  like  them  evident  signs 
of  phthisis,  were  placed  in  a  place  constantly  kept  of  a  mild  tem- 
perature: most  of  them  recovered  their  strength,  and  some  months 
afterwards  were  completely  cured. 


PHTHISIS   PULMONALIS,   OR    CONSUMPTION.  543 

"  It  is  important  to  compare  the  lungs  of  the  cured  pullets  with 
lungs  of  those  which  had  died  of  phthisis.  In  the  latter,  the 
lungs,  the  trachea,  and  the  bronchia  were  filled  with  purulent 
matter,  of  a  deep  gray,  and  of  a  foetid  odour,  sprinkled  with  an 
infinite  number  of  black  points  ;  the  tissue  of  the  lungs  was  gorged 
with  blood,  softened,  as  if  putrified  ;  many  of  its  cells  were  red 
and  full  of  pus ;  others  exhibited  black  points  similar  to  those 
with  which  the  purulent  matter  was  sprinkled,  and  in  many  of 
these  points  there  was  a  small,  hard,  crepitating  body,  of  a  white 
colour,  and  of  an  osseous,  corneous  appearance.  In  those  pul- 
lets which  were  cured,  some  portions  of  the  lungs  exhibited  no- 
thing but  depressed,  closed  cells,  where  traces  of  black  points 
which  they  had  contained  when  diseased  were  still  visible. 

"From  all  these  experiments,  M.  F.  concludes,  1st,  that  cold 
does  not  act  solely  upon  the  organization  and  life  collectively 
and  in  mass;  2d,  that  it  acts  especially,  and  by  a  particular  and 
determined  action,  upon  the  respiratory  organ ;  3d,  that  it  acts 
upon  this  organ  in  two  distinct  modes — one  which  produces  an 
acute  inflammation,  and  is  promptly  fatal ;  the  other  which 
produces  a  chronic  inflammation,  which  is  phthisis  pulmo- 
nalis;  4th,  finally,  that  a  moderate  and  constant  warmth  always 
prevents  the  attack  of  phthisis  pulmonalis,  and  that  often  even 
after  the  attack  it  arrests  its  progress. 

"  These  experiments  as  yet  only  bear  upon  accidental  or  ac- 
quired phthisis ;  the  author  proposes  to  extend  them  to  congeni- 
tal or  tubercular  phthisis,  to  which  certain  mammifera,  the 
ruminantia  and  gnawers,  are  particularly  subject.  But  we  see 
already  from  these,  on  the  one  hand,  the  assistance  we  may  de- 
rive in  illuminating  human  pathology  by  observations  on  the 
diseases  of  animals,  and  they  show  clearly,  on  the  other,  that 
the  good  effects  which  have  long  been  observed  from  mild  cli- 
mates, arise  from  their  producing  the  cicatrization  of  the  ulcera- 
tions  and  inflammation  of  the  lungs  caused  by  cold  climates."* 

1824.  From  all  that  has  been  said  on  the  subject  of  phthisis, 
it  must  be  evident,  that  its  treatment  must  be  more  regulated  by 
the  existence  of  symptoms,  than  any  view  to  a  radical  cure.   The 
inconveniences  which   the  phthisical  patient  experiences  vary 
during  the  course  of  the  disease;  one  of  the  earliest  for  the  most 
part,  and  the  most  pertinacious  and  distressing,  is  cough.     This 
sometimes  becomes  so  urgent  as  to  deprive  the  patient  of  sleep, 
especially  during  the  night. 

1825.  Very  many  articles  have  been  tried  with  a  view  to 
controul  or  subdue  this  distressing  symptom;  but  we  believe  that 
all  experience  at  this  time  decides  in  favour  of  opium,  in  one 

•  American  Journal  of  the  Medical  Sciences,  Feb.  1831, 


544  PHTHISIS   PULMONAUS,  OR    CONSUMPTION1. 

form  or  other.  Hemlock,  henbane,  digitalis,  &c.  have  been  se- 
verally extolled ;  but  their  superiority  over  opium  for  cough  is 
not  sanctioned  by  trial.  We  therefore  rely  mainly  upon  this  drug 
for  the  relief  of  this  harassing  symptom.  It  is  generally  admi- 
nistered at  night  with  the  hope  of  procuring  sleep;  and  for- 
tunate it  is  for  the  patient,  when  idiosyncrasy  does  not  prevent 
its  employment,  for  we  know  of  no  substitute;  for  as  a  general 
rule  it  is  found,  that  where  opium  disagrees,  the  other  narcotics 
are  frequently  ineligible. 

1826.  It  is  generally  best  administered  in  small  doses,  and 
these  repeated  pro  re  nata,  at  three  or  four  hour's  intervals.  The 
denarcotized  laudanum  is  preferable  to  the  common  under  any 
circumstance ;  and  it  is  particularly  called  for,  where  the  other 
form  disagrees.  It  is  perhaps  eight  or  ten  per  cent,  weaker  than 
the  officinal  laudanum.  We  have  found  in  a  number  of  instances, 
that  the  morphia  will  succeed  when  no  other  preparation  will ; 
it  therefore  always  merits  a  trial,  when  opium  in  other  forms 
disagree.  It,  or  its  sulphate,  may  be  given  in  solution,  or  in  the 
form  of  a  pill,  in  doses  of  a  sixth  or  eighth  of  a  grain;  these  quan- 
tities being  about  equal  to  twenty  or  twenty-five  drops  of  lauda- 
num. If  the  former  form  be  preferred,  it  should  be  so  calculated, 
that  a  tea-spoonful  of  the  julep  should  contain  that  quantity  of 
the  morphia;  the  following  is  the  form  we  generally  employ: — 

B.     Morphia 

Pulv.  gum  Arab. 
Aq.  cinnam.  simp. 
Aq.  font.    - 
Sacch.  alb. 


A  tea-spoonful  of  this  is  to  be  given  at  bed-time,  and  repeated  in 
three  hours  if  the  cough  persist,  or  is  again  troublesome.  A  tea- 
spoonful  of  this  formula  is  supposed  to  hold  one  drachm  of  the 
julep.  If  pills  be  the  choice  of  the  patient,  we  prescribe  each  to 
contain  the  quantity  mentioned  above,  taking  care  to  have  the 
morphia  well  united  with  some  other  substance,  to  insure  its  re- 
gular division,  as  well  as  to  augment  the  bulk  of  the  pills;  the 
following  is  a  good  form: — 

R.     Morphia     -  gr.  j. 

Pulv.  rhaei  -     gr.  viij. 

Conserv.  rosar.  vel.  syr.  commun.  q.  s. 

M.  f.  pil.  viij. 
One  of  these  to  be  used  as  directed  for  the  solution. 

1827.  Demulcent  drinks  should  be  constantly  used,  with  as 
much  freedom  as  the  stomach  will  bear,  or  thirst  require.     The 


PHTHISIS    PULMONALIS,    OR    CONSUMPTION.  545 

most  common  in  use  is  the  flaxseed  tea,  and  it  is  nearly  as  good 
perhaps  as  any.  The  slippery-elm  bark  tea,  however,  generally 
merits  the  preference,  as  it  is  more  acceptable  for  the  most  part 
to  the  patient.  The  drinks  may  be  varied  as  caprice  may  direct, 
or  disgust  require ;  therefore,  gum  Arabic  water,  barley  water, 
rice  water,  toast  water,  baum  tea,  bran  tea,  &c.  may  be  had  re- 
course to  in  their  turn. 

1828.  When  expectoration  is  not  free,  and  the  patient  oppress- 
ed, thirty  or  forty  drops  of  the  compound  syrup  of  squills  seems 
to  answer  better  than  most  other  preparations.  For  its  composi- 
tion, see  par.  1489.     This  can  be  repeated  as  occasion  may  re- 
quire.    Should  this  quantity  sicken  the  stomach,  the  quantity 
must  be  reduced. 

1829.  Though  we  cannot  hold  out  a  prospect  of  eventual  re- 
covery, yet  are  we  bound  to  employ  only  such  means  as  will  be 
best  suited  to  the  immediate  condition  of  the  patient ;  for  we  are 
of  opinion,  that  much  injury  is  done,  and  even  life  itself  abridged, 
by  that  recklessness  of  consequences  which  the  utter  despair  of 
recovery  produces,  by  indulging  the  patient's  waywardness  of 
desire  for  food  or  medicine.     The  constantly  consuming  fever, 
the  exhausting  sweats,  and  the  wasting  diarrhoea,  certainly  merit 
our  closest  attention,  if  we  mean  the  patient  shall  derive  all  the 
aid  from  medical  care  that  it  is  capable  of  affording.     With  this 
in  view,  the  diet  and  remedial  means,  (as  far  as  they  can  be  con- 
sidered such,)  should  be  carefully  selected,  and  faithfully  persist- 
ed in ;  for  by  moderating  the  symptoms  just  named  by  judicious 
and  varied  means,  we  may  support  life  sufficiently  long  for  na- 
ture to  effect  a  cure.  See  case,  par.  1710. 

1830.  For  these  purposes,  the  most  bland,  but  highly  nutri- 
tious substances,  should  be  employed  for  food — as  sago,  tapioca, 
rice  jelly,  arrow  root,  &c.     No  animal  substance  should  be  per- 
mitted in  any  shape  or  form.  Milk,  where  it  agrees,  can  be  taken 
with  these  substances ;  and  rennet  whey  may  be  almost  always 
freely  indulged  in. 

1831.  We  know  of  no  remedy  for  the  fever;  though  when 
excessive,  its  violence  seems  to  be  abated  by  small  and  repeated 
doses,  (twenty  drops,)  of  sweet  nitre,  (aether,  nitros.)  in  cold 
water;  or  by  the  occasional  use  of  the  acetate  of  soda,  and  not 
covering  the  body  too  warmly,  especially  during  the  night.  The 
deluging  sweats  are  frequently  abated  by  the  elixir  vitriol,  in 
small  and  repeated  doses ;  by  a  free  use  of  lime  water,  and  by 
the  acetate  of  lead  in  two  or  three  grain  doses  slightly  guarded 
with  opium  four  or  five  times  in  the  twenty-four  hours.  By  mo- 
derating the  quantity  of  bed-clothes,  and  sometimes  by  the  pa- 
tient being  kept  awake  at  the  hour  they  are  wont  to  appear  at. 
The  diarrhoea  is  best  restrained  by  the  occasional  use  of  prepared 

69 


546  PERICARDITIS. 

chalk  and  laudanum ;  the  acetate  of  lead  has  been  found  occasion- 
ally beneficial,  as  has  the  free  use  of  the  juice  of  sweet  oranges. 
The  diarrhoea,  however,  is  rarely  controlled  beyond  a  short  pe- 
riod at  a  time ;  and  it  has  been  supposed  to  constantly  alternate 
with  the  night  sweats — but  this  is  an  error.  Post  mortem  exa- 
minations abundantly  prove,  that  the  diarrhoea  proceeds  from  a 
tuberculous  and  ulcerous  state  of  the  mucous  membrane  of  the 
intestines.  (See  par.  1746.) 

SECT.  IX.  PERICARDITIS,  OR  INFLAMMATION  OF  THE  PERI- 
CARDIUM. 

1832.  The  pericardium  may  be  either  partially,  or  entirely 
inflamed.  The  symptoms  to  which  this  inflammation  gives  rise, 
are  certainly  very  far  from  being  either  so  well  pronounced,  or 
so  peculiar,  as  to  leave  no  doubt  of  the  part  from  whence  they 
originate.     Thus,  the  heart  itself  may  be  inflamed  only,  (though 
this  is  confessedly  very  rare,)  or  the  pericardium  may  at  the 
same  time  be  affected,  yet  no  discoverable  difference  exists  in 
the  symptoms ;  but  fortunately,  this  obscurity  does  no  .injury  to 
our  therapeutical  views. 

1833.  The  surface  of  the  pericardium  in  contact  with  the 
heart,  is  the  one  that  becomes  inflamed ;  its  redness  is  however, 
not  great  in  the  acute  form  ;  and  as  this  membrane  is  a  serous 
one,  the  inflammation  resembles  that  which  may  attack  a  serous 
tissue  in  any  other  portion  of  the  body,  except  perhaps  agreeably 
to  Laennec,  that  the  albuminous  exudation  is  in  greater  propor- 
tion in  pericarditis  than  in  either  pleuritis  or  peritonitis ;  being 
in  the  two  latter,  from  twenty  to  twenty*five  times  as  much  se- 
rum as  coagulated  lymph ;  while  in  the  former,  they  are  nearly 
equal.     Serum  however,  is  occasionally  found  in  pretty  consi- 
derable quantity ;  Laennec  says  a  pound,  and  Corvisart  has  seen 
as  much  as  four  pounds.     This  serum  is  generally  limpid,  of  a 
pale  yellow ;  and  does  not  contain  a  sufficient  number  of  albumi- 
nous coagula,  to  render  it  turbid,  though  now  and  then,  as  in 
pleurisy,  it  is  found  bloody. 

1834.  Laennec  states  that  the  effusion  is  very  considerable  in 
the  commencement  of  the  disease,  but  diminishes  by  absorption 
quickly  as  the  violence  of  the  disease  abates ;  for  when  this  takes 
place  the  quantity  of  serum  and  lymph  is  about  equal.    In  some 
very  violent  cases,  there  is  no  serum;  instead  of  this,  a  strongly 
concreted  albumen  is  found  filling  the  whole  pericardiac  cavity, 
uniting  the  heart  and  large  vessels  to  the  exterior  or  loose  por- 
tion of  the  pericardium.     In  these  cases  it  is  supposed  that  the 
effused  serum  has  been  quickly  absorbed,  and  the  two  layers  of 
false  membrane,  that  is,  the  layer  which  the  heart  itself  fur- 


PERICARDITIS.  547 

nishes,  and  that  yielded  by  the  serous  surface  of  the  pericar- 
dium, became  cemented  together,  though  Laennec  confesses, 
that  it  is  not  impossible,  in  some  instances,  that  the  more  solid 
exudation  may  be  the  only  one.  When  the  disease  terminates 
favourably,  the  "  pseudo-membranous  exudation,  after  a  certain 
time,  is  converted  into  cellular  substance,  or  rather  into  laminae 
of  the  same  nature  as  the  serous  membranes."  These  constitute 
the  general  appearances  of  the  pericardium  and  heart  under  in- 
flammation.— besides  these,  pathologists  remark  many  others, 
but  as  they  are  not  constant  in  their  appearance,  we  shall  pass 
them  over. 

1835.  This  disease  has  been  divided  into  two  forms — the  acute 
and  the  chronic.    In  the  acute  form,  the  redness  is  just  noticed, 
is  not  very  great,  and  even  this  exists  but  partially.     The  cha- 
racter of  this  inflammation  is  peculiar,  agreeably  to  Laennec,  "it 
looks  as  if  the  surface  of  the  membrane  was  covered  here  and 
there  with  little  specks  of  blood  very  close  to  each  other."     In 
some  cases  an  albuminous  exudation  covers  the  whole  surface  of 
the  heart,  pericardium,  and  large  vessels — this  false  membrane 
the  same  author  tells  us,  has  given  rise  to  a  singular  error,  hav- 
ing been  mistaken  for  a  variolus  eruption  in  subjects  dead  of  the 
small-pox.     This  offers  a  caution  to  those  who  are  engaged  in 
pathological  researches,  not  to  mistake  one  phenomenon  for  an- 
other. 

1836.  It  would  seem,  that  the  serous  membrane  of  Tthe  peri- 
cardium, has  laws  somewhat  peculiar  to  itself;  or  at  least,  appa- 
rently different  from  those  which  govern  in  other  parts  the  same 
kind  of  membrane,  as  the  pleura  or  peritoneum.  The  consistency 
of  this  membranous  exudation,  is  greater  in  the  pericardium, 
than  when  it  is  thrown  out  in  pleurisy,  and  adheres  more  firmly 
to  the  subjacent  parts.     And  besides,  it  seems  to  have  a  greater 
self-preserving  power,  than  the  pleura  and  peritoneum,  if  the 
causes  which  produce  inflammation  in  the  latter  membranes,  be 
identical  with  those,  which  excite  it>  in  the  former,  since  nothing 
is  more  rare  than  simple  pericarditis;  and  even  when  complicated 
is  very  much  less  frequent  than  pleurisy  or  peritonitis.     There 
is  a  morbid  appearance  of  the  heart,  about  the  origin  and  seat  of 
which  Corvisart  and  Laennec  disagree ;  these  are  white  opaque 
patches  of  various  sizes ;  they  are  about  the  thickness  of  the  nail, 
and  have  a  pretty  firm  consistency.     Corvisart  thinks  they  are 
produced  without  previous  inflammation,  -and  are  situated  be- 
neath the  serous  covering  of  the  pericardium ;  while  Laennee 
contends,  they  are  the  result  of  inflammation,  as  there  is  no  in- 
stance he  says  of  an  albuminous  exudation  without  inflammation; 
and  that  they  are  situated  upon  the  membrane  as  he  has  been 
able  to  remove  the  one  from  the  other. 


548  PERICARDITIS. 


Chronic  Pericarditis. 

1837.  This  form  is  said  to  be  very  much  more  frequent,  than 
the  acute;  existing  ten  times,  out  of  twelve.     The  inflammation 
is  much  more  general,  and  is  much  more  florid;  and  "  the  red- 
ness is  formed  by  the  close  approximation  of  minute  points, 
which  look  as  if  applied  by  a  pencil."     It  commonly  occupies 
the  whole  internal  surface  of  the  serous  membrane.     This  form 
is  rarely  accompanied  by  the  "pseudo-membranous  exudation; 
and  when  it  exists,  it  is  thin,  soft,  friable,  and  entirely  resem- 
bling a  layer  of  very  thick  pus." 

1838.  Laennec  says  in  this  form  of  pericarditis,  "the  muscu- 
lar substance  of  the  heart  loses  its  colour  and  becomes  whitish, 
as  if  it  had  been  macerated  several  days  in  water.      This  loss  of 
colour  is  attended  sometimes  by  a  considerable  degree  of  soften- 
ing, and  at  other  times,  the  consistence  is  natural."     This  loss 
of  colour,  most  writers  think  has  been  occasioned  by  inflamma- 
tion— but  this  is  denied  by  Laennec;  "we  can  never  be  sure," 
he  says,  "  of  the  existence  of  inflammation  in  a  muscular  organ, 
unless  we  find  pus  deposited  among  its  fibres."  p.  663. 

Signs  of  Pericarditis. 

1839.  It  is  agreed,  by  all  the  writers  almost  upon  this  disease, 
that  no  other  presents  so  much  obscurity  of  symptoms ;  or  per- 
haps so  much  uncertainty  of  its  existence;  consequently  its  diag- 
nosis is  extremely  difficult.  This  perhaps  is  owing  to  its  seldom 
or  never  being  presented  to  us,  in  its  simple,  uncomplicated 
form ;  that  is,  where  the  inflammation  is  limited  to  the  serous 
membrane  of  the  pericardium  alone;  this  being  the  case,  it  can- 
not present  its  own  insulated  symptoms,  by  which  we  might  be 
enabled  to  detect  its  presence. 

1840.  The  following  are  the  signs  laid  down  by  Corvisart, 
when  the  inflammation  of  the  pericardium  predominates  over  the 
other  affections,  which  complicate  it.      "Breathing  difficult  or 
confined,  high,  frequent  and  interrupted.     A  pain  about  the  re- 
gion of  the  heart;  the  patient  feeling  an  internal  painful  heat  and 
anxiety ;  the  hand  if  applied  to  this  part  feels  a  palpitation  and 
tumult  more  or  less  marked.    Commonly,  there  is  cough;  but  it 
4s  dry  and  distressing ;  the  pulse  is  small,  contracted,  frequent, 
and  rather  rapid  ;  the  face  expressive  of  anguish ;  urine  scarce ; 
in  a  word,  the  whole  train  of  symptoms  which  denote  extreme 
irritation  of  the  whole  system,  syncope,  &c." 

1841.  Laennec  cautions  against  "too  implicit  confidence  in 
these  signs,  even  when  they  coexist;  for  pericarditis  may  assur- 


PERICARDITIS.  549 

edly  exist  without  them,  and  they  without  pericarditis.  The 
accumulation  of  blood  in  the  heart,  and  polypus  concretions, 
the  consequence  of  this,  give  rise  to  precisely  the  same  symp- 
toms."* From  this  it  would  appear  that  we  have  no  pathogno- 
monic  sign  in  pericarditis;  and  that  its  existence  can  only  be  pre- 
sumed, from  symptoms  more  or  less  founded  in  reality.  For 
acute  pericarditis  is  almost  always  complicated  with  an  inflam- 
mation of  the  pleura  and  lungs,  especially  of  its  contiguous  side. 

1842.  The  chronic  form  of  this  disease,  is  much  more  fre- 
quent than  the  acute,  as  we  observed  above ;  it  is  also  much  more 
extensively  complicated;  it  is  almost  sure  to  be  united  to  all  the 
organic  affections  of  the  heart,  and  with  even  other  affections  of 
the  pericardium  itself,  as  dropsy,  cartilaginous  condition,  &c. ;  it 
is  implicated  in  the  various  disorders  of  the  pleura,  lungs,  me- 
diastinum, diaphragm,  and  stomach,  as  well  as  the  acute  form. 
The  most  common  complication  is  that  of  the  heart;  nor  is  this 
surprising  since  the  same  membrane  which  lines  one,  covers  the 
other;  and  when  the  portion  which  covers  the  heart  becomes  in- 
flamed, it  may  penetrate  and  involve  the  substance  of  the  heart. 
In  this  it  resembles  the  pleura  and  lungs,  as  we  seldom  see  one 
much  injured,  without  the  other  being  implicated,  though  this 
is  not  absolutely  a  necessary  consequence. 

1843.  The  acute  form,   generally  attacks   adults  in  robust 
health  and  in  the  vigour  of  life ;  while  the  chronic  may  take 
place  at  any  period  of  life,  as  it  is  generally  but  a  consequence 
of  other  diseases. 

Causes. 

1844.  The  causes  of  pericarditis,  may  be  all  such  as  are  capa- 
ble of  exciting  inflammation  in  any  of  the  similar  tissues — as  a 
sanguine  temperament;  cold;  sudden  check  of  perspiration;  the 

*  In  affections  of  the  heart,  we  have  lately  been  led  to  the  opinion,  that 
"polypus  concretions  should  not  be  looked  upon  as  a  diseased  condition  of 
this  organ,  but  as  a  last  effort  of  nature  to  relieve  it  from  its  embarrassments, 
if  not  to  effect  a  cure.  It  has  struck  us  with  much  force  of  probability,  that 
these  concretions  are  the  result  of  two  conditions  of  the  system  in  general, 
and  the  heart  in  particular;  namely,  1st,  where  the  heart  is  inflamed;  and  2d, 
where  the  system  is  much  exhausted  of  blood.  In  the  first  supposition,  they 
appear  to  be  formed  for  the  purpose  of  moderating  the  impulse  of  the  influent 
blood  into  the  ventricle,  the  pulmonary  artery,  and  the  aorta;  and  thus  dimi- 
nishing its  stimulating  force  upon  each  of  these  irritated  surfaces.  And  in  the 
second,  they  appear  to  be  intended  to  occupy  these  cavities,  that  the  heart 
may  be  enabled  to  circulate  with  more  advantage,  the  diminished  quantity  of 
blood;  and  by  which  effort,  life  is  longer  preserved.  We  throw  out  these  con- 
jectures for  no  more  than  they  are  worth;  but  at  the  same  time  we  indulge  a 
hope,  they  may  awaken  attention  in  'those,  who  may  make  pathological  re- 
search an  object  of  attention. 


550  CARDITIS. 

suppression  of  accustomed  evacuations;  errors  in  diet;  metastases, 
especially  rheumatism  and  gout;  blows  or  other  violences,  &c. 

Treatment. 

1845.  From  what  has  been  said,  it  is  evident,  that  in  pre- 
scribing for  pericarditis  we  take  for  granted  that  the  disease 
exists,  rather  than  feeling  an  assurance,  that  it  is  present — we 
have  however  observed,  that  the  acute  form  of  this  disease  was 
perhaps  complicated  by  acute  inflammation  of  the  parts  in  the 
immediate  vicinity  of  the  heart,  as  the  pleura,  lungs,  mediasti- 
num, and  diaphragm,  and  that  while  this  complication  rendered 
the  diagnosis  of  pericarditis  extremely  obscure,  it  nevertheless 
rendered  the  nature  of  the  treatment  more  certain,  however  un- 
successful it  might  prove.   Indeed,  from  all  testimony  upon  this 
point  it  would  seem,  that  nothing  but  dissection  can  determine 
the  previous  existence  of  pericarditis;  consequently  that  as  it  has 
no' marked  characters  on  which  we  can  rely,  that  we  may  often 
prescribe  for  this  disease  where  it  does  not  exist;  while  on  the 
contrary,  it  may  have  been  present  when  it  was  not  suspected. 

1846.  But  as  this  disease  is  rarely,  if  ever,  simple,  or  uncom- 
plicated ;  and  as,  when  in  combination,  it  is  always  connected 
with  affections  of  high  inflammatory  character,  the  mode  of  treat- 
ment must  be  such,  as  pleurisy  or  pneumonia,  with  which  it  is 
so  commonly  connected,  require— such  as  blobd-letting,  both 
general  and  local,  &c.  but  at  the  same  time  always  having  regard 
to  the  nature  and  type  of  the  disease  with  which  this  affection 
may  be  associated.     In  the  chronic  form  we  have  more  time  to 
combat  the  disease,  but  absolutely  perhaps  less  chance,  from  the 
changes  of  structure,  &c.  the  parts  have  already  undergone. 

1847.  The  history  of  this  disease,  should  teach  us  a  more  cau- 
tious language  than  is  oftentimes  employed,  when  giving  a  name 
to  a  disease,  or  when  relating  our  cures ;  it  is  not  very  uncom- 
mon to  hear  a  disease  called  pericarditis ;  or  its  cure  boasted  of, 
when  no  certainty  could  be  obtained  of  the  nature  of  the  affection 
purporting  to  be  an  inflammation  of  the  pericardium. 

SECT.  X. — CARDITIS. 

1848.  The  same  obscurity  prevails  in  cases  of  carditis — this 
disease  furnishes  no  pathognomonic  sign;  and  perhaps  for  rea- 
sons similar  to  those  we  have  expressed  for  pericarditis;  namely, 
that  it  is  seldom  or  never  found  simple,  or  uncomplicated ;  and 
when  complicated,  it  is  with  affections  similar  to  those  enume- 
rated as  embarrassing  inflammation  of  the  pericardium.     The 
causes  are  similar  to  those  which  cause  pleurisy,  &c.     But,  per- 


CARDITlS.  551 

haps  the  heart  is  more  liable  to  become  affected  by  metastasis, 
than  the  pericardium ;  hence,  it  is  supposed  not  unfrequently  to 
become  the  secondary  seat  of  disease,  especially  of  gout  and 
rheumatism.  Practical  writers  offer  no  other  mode  of  treatment 
for  this  disease,  than  for  pericarditis.* 

*  Since  writing  the  above,  we  have  met  with  an  account  of  "  the  acute  idio- 
pathic  inflammation  of  the  heart,"  as  extracted  from  Hecker's  Literary  Annals 
of  Medicine;  the  account  is  given  by  Dr.  Krause.  Dr.  K.  commences  his  ac- 
count by  the  diagnosis  of  this  ^rare,  but  terrible  disease,  as  laid  down  by  Dr. 
Heim,  who  had  witnessed  three'cases  of  it.  Dr.  Krause  esteems  the  diagnostics 
of  Dr.  Heim  as  accurate,  valuable,  and  pathognomonic.  He  declares  the  dis- 
ease "begins  with"  shivering  and  trembling  of  the  whole  body,  and  intermit- 
tent chill,  which  latter  may  continue  during  twenty-four  hours,  but  is  followed 
by  very  little  or  no  heat.  There  is  no  acute  stitch  felt,  but  pains  in  the  heart 
precede  the  distinct  attack  twenty-four  hours.  Sometimes  the  disease  comes 
on  suddenly.  The  patient  has  no  cough;  if  in  any  instance  cough  occurs,  it  is 
entirely  dry,  neither  mucus  nor  blood  being  expectorated.  In  the  commence- 
ment the  patient  has  the  greatest  anguish  and  the  most  agonizing  pain,  not  in 
the  chest  generally,  but  immediately  in  the  heart  itself.  The  patient  shrieks 
out,  and  is  not  quiet  more  than  a  second,  repeating  with  great  force  the  same 
word  three  or  four  times,  to  express  his  most  distressing  sensations.  He  does 
not  lie  still  an  instant,  but  tosses  himself  about  in  bed  like  one  half  distracted, 
while  his  arms  and  head  are  in  continual  motion.  The  patient  presses  upon 
the  region  of  the  heart,  and  if  pressure  be  made  by  a  bystander,  he  impetu- 
ously demands  that  it  shall  be  increased.  The  countenance  is  always  extremely 
pale.  The  chest  is  elevated,  and  the  head  which  is  in  perpetual  motion  is 
thrown  more  backwards.  The  face  and  hands  are  quite  cold.  Before  each 
necessary  bleeding,  the  pulse  throughout  is  not  to  be  felt.  The  patient  feels 
every  movement  of  the  heart,  and  even  complains  of  its  painful  throbbings; 
yet  when  the  physician  applies  his  hand  to  the  chest,  he  cannot  discover  the 
least  irregularity.  The  stronger  the  pulse  of  the  heart  is,  the  greater  is  the 
pain  felt  in  the  organ;  it  seems  to  the  patient  to  strike  upon  a  wounded  spot. 
He  is  nauseated,  but  does  not  vomit;  the  greater  his  thirst  is,  so  much  more 
does  he  refuse  to  drink,  even  when  a  glass  of  water  is  held  to  his  mouth.  He 
is  very  loquacious,  even  when  otherwise  naturally  silent;  we  might  also  say 
physically,  what  the  scriptures  assert  morally,  that  "out  of  the  fulness  of  the 
heart,  the  mouth  speaketh."  Fainting  and  delirium  are  not  uncommon. 

"A  copious  bleeding  is  followed  by  so  great  an  alleviation  of  anguish  and 
pain,  which  lasts  for  several  hours,  that  the  patient  thinks  himself  quite  cured. 
But  the  symptoms  suddenly  return  after  the  cessation.  The  anguish  and  pain 
is  increased  by  warm  applications  to  the  chest,  and  the  patient  throws  them 
off.  If  the  treatment  be  neglected,  or  improper,  the  patient  dies  either  in 
consequence  of  polypous  formations  on  the  internal  or  external  surface  of  the 
pericardium,  or  with  adhesions  of  the  heart  to  this  membrane,  and  effusions  of 
pus  or  water  into  the  cavity  of  the  pericardium. 

"  The  case  related  by  Dr.  Krause,  in  which  he  had  the  assistance  of  Dr. 
Heim,  manifested  the  above  symptoms  in  a  striking  manner.  By  free  and  am- 
ple bleeding,  and  the  use  of  digitalis,  &c.  the  patient  was  quite  restored  to 
his  usual  health  in  ten  or  twelve  days." — Amer.  Journ.  of  Med.  Scien.  Vol.  HI, 
p.  435. 


552  PERITONITIS. 


CHAPTER  XL 

DISEASES  OF  THE  ABDOMEN. 
SECT.  I. — PERITONITIS. 

1849.  IT  has  not  been  but  a  short  time,  that  the  affections  of 
the  peritoneum  have  been  well  understood ;  and  it  is  principally 
owing  to  the  genius  and  industry  of  the  lamented  Bichat,  (though 
to  a  certain  extent  anticipated  by  Pinel,)  that  the  profession  is 
indebted  for  their  clear  exposition.     Before  his  time,  it  was  not 
known,  that  the  peritoneum  could  be  inflamed,  either  generally 
or  partially,  without  involving  either  of  the  several  viscera  over 
which  it  passed ;  or  that  either  of  these  viscera  could  have  its 
parenchyma  inflamed,  without  this  affection  being  transmitted  to 
its  investing  membrane,  the  peritoneum.     Modern  pathological 
researches  have,  however,  settled  this  point  now ;  and  the  truth 
of  Bichat's  declaration  on  this  subject  rests  upon  so  solid  a  foun- 
dation at  this  moment,  as  not  to  be  shaken,  though  Lieutaud  and 
some  others  pretend,  that  dissection  never  shows  the  peritoneum 
in  a  state  of  inflammation,  without  the  viscera  it  covers  being 
implicated. 

1850.  This  was  certainly  the  view  taken  of  abdominal  in- 
flammation, by  all  the  older  nosological  writers;    and    hence, 
Cullen  made  peritonitis  a  genus,  which  comprehended  several 
species — as  one  or  other  of  the  viscera  over  which  it  passed, 
was  thought  to  be  involved.     Thus,  if  the  peritoneum  of  the 
omentum  was  inflamed,  the  inflammation  was  called  by  its  name; 
and  so  on  with  the  other  viscera  of  the  abdomen;  though  Cullen 
confessed  it  was  difficult  to  distinguish  these  phlegmasise  from 
each  other,  by  any  marks  or  signs;  nor  did  he  consider  this  a 
matter  of  much  moment ;  for  if  known,  they  all  required  to  be 
treated  as  inflammation  in  general.     Hence,  we  have  gastritis, 
enteritis,  cystitis,  hysteritis,   Sic.  &c.  proving,  that  those  who 
made  these  distinctions,  were  persuaded,  that  an  inflammation 
of  the  peritoneum  did  not  exist,  without  these  viscera  partici- 
pating in  it. 

1851.  It  is  therefore  a  matter  of  great  practical  value,  that 
this  subject  should  be  better  comprehended  than  it  is  generally ; 
with  this  in  view,  we  shall  give  the  best  tested  opinions  upon 
this  point,  both  anatomically  and  pathologically,  that  the  mode 
of  treating  the  inflammation  of  the  several  tissues  composing  the 


PERITONITIS.  553 

abdominal  organs,  shall  be  more  easily  understood.  But  to  com- 
prehend the  various  phenomena  presented  by  a  diseased  organ, 
requires  an  acquaintance  with  the  brilliant  discoveries  of  Bordeu 
and  Bichat,  of  the  nature  of  the  more  intimate  and  varied  struc- 
ture, of  our  bodies. 

1852.  M.  Gasc  has  observed,*  that  "the  researches  of  Bi- 
chat upon  the  tissues  which  enter  into  the  composition  of  our  or- 
gans, have  led  us  to  believe  that  an  inflammation  of  the  perito- 
neum may  exist,  independently  of  the  organs  beneath  it.  And 
that  these  organs  are  composed  of  several  tissues,  whose  struc- 
ture and  nature  are  different,  and  their  affections  vary,  as  it  may 
be  one  or  other  of  these  tissues  that  may  be  primarily  inflamed; 
for  instance,  the  mucous  membrane  of  the  stomach,  intestines, 
the  bladder,  the  uterus,  &c.  have  both  acute  and  chronic  ca- 
tarrhs; for  the  peritoneum,  serous  inflammations ;  for  the  mus- 
cles, a  particular  inflammation,  though  we  know  not  at  present 
the  mode  of  these  alterations.  But  it  is  certainly  always  true  to 
say,  that  the  stomach,  the  intestines,  the  bladder,  the  uterus,  &c. 
are  never  attacked  by  these  three  affections,  at  one  and  the  same 
time ;  that  the  inflammation  is  always  confined  in  the  first  in- 
stance to  a  single  tissue ;  and  when  this  is  acute,  it  is  only  the 
peritoneum  that  is  diseased,  the  other  tissues  remaining  sound." 
"And  that  those  who  suppose,  that  this  inflammation  depended 
upon  the  organs  over  which  it  passed,  was  in  error,  since  the  in- 
flammation of  the  peritoneum  is  never  confined  to  the  limits  of 
the  organ,  but  spreads  itself  indefinitely  beyond  it."  This  part 
then,  of  pathological  anatomy,  seems  to  be  so  well  established  at 
this  time,  that  we  take  it  at  all  times  for  granted,  as  may  be  seen 
in  treating  of  the  inflammations  of  the  several  viscera  of  the  ab- 
domen, especially  in  the  forms  peculiar  to  the  female.t 

1853.  Few  tissues  of  the  body  are  so  susceptible  of  inflam- 
mation as  the  peritoneum;  this  disposition  it  seems  to  derive 
from  its  very  organization ;  hence,  the  variety  of  causes  which 
may  urge  it  to  inflammation.  It  may  be  produced  from  external, 
as  well  as  from  internal  causes ;  mechanical  violences,  as  strong 
compression,  blows,  falls,  wounds,  &c.     Chemical  irritations,  as 
the  injection  of  stimulating  liquids  within  the  cavity  of  the  belly; 
unabsorbed  effusions  of  blood,  pus,  serum,  bile,  &c.     The  inter- 
nal may  be,  pressure  from  pregnancy,  either  uterine  or  extra- 
uterine,  enlargement  of  the  ovaries,  &c.      Violent  and  long-con- 
tinued efforts,  which  may  put  the  peritoneum  upon  the  stretch, 
as  lifting  heavy  weights,  jumping,  carrying  heavy  loads,  &c. 

1854.  Cold  suddenly  applied  to  the  body,  especially  if  it  be 

*  Diet,  des  Sciences  Med.  Art.  Peritonite. 

f  See  Hysteritis  and  Puerperal  Fever.  Diseases  of  Females,  by  the  Author. 

70 


554  PERITONITIS. 

in  a  state  of  perspiration,  or  if  it  be  long  and  partially  applied; 
too  cold  water  in  bathing,  &c.;  sudden  and  powerful  passions  or 
emotions  of  the  mind  ;  the  sudden  suppression  of  the  lochia  or 
menses,  in  females,  is  also  said  to  be  capable  of  producing  perito- 
nitis; an  epidemic  constitution  of  the  air  we  are  told  has  given  rise 
to  this  disease;  in  proof  of  which  several  of  the  French  army  sur- 
geons or  physicians,  might  be  cited ;  Pujol  and  Broussais  quote 
instances  of  this  kind ;  and  Gasc  declares  he  has  seen  it  more 
than  once  in  the  hospitals  of  the  army,  and  especially  at  Dant- 
zick,  (loc.  cit.)  It  may,  and  is  perhaps,  very  often  produced  by 
metastasis. 

1855.  These  causes  may  act  suddenly,  and  excite  the  acute 
form  of  this  disease;  or  they  may  act  more  slowly,  and  produce 
the  chronic ;  it  will  therefore  be  proper  to  divide  this  disease  into 
the  acute  and  chronic  peritonitis. 

Acute.  Peritonitis, 

1856.  Is  that  form  of  the  disease  which  declares  itself  sud- 
denly; is  preceded  by  causes  more  or  less  evident;  where  the 
symptoms. are  violent,  and  the  progress  rapid.     It  may  attack 
persons  of  any  age,  or  of  either  sex,  but  more  frequently  the 
young  and  plethoric,  but  especially  women  after  delivery.* 

1857.  .This  disease  generally  invades  by  a  chill,  and  signs  of 
debility — the  chill  sometimes  is  not  distinctly  marked,  and  oc- 
casionally it  is  of  very  long  continuance ;  this  is  succeeded  by 
heat  of  various  intensities;    head-ache,  and  sense  of  tightness 
around  the  stomach,  or  epigastric  region.   So  soon  as  the  inflam- 
mation is  established,  the  belly  becomes  painful  to  the  slightest 
pressure ;  so  much  so  sometimes,  as  not  to  be  able  to  support 
even  the  weight  of  the  bed-clothes,  or  the  lightest  application. 
The  degree  of  pain  will  be  in  proportion  to  the  extent  and  inten- 
sity of  the  inflammation.     Sometimes  it  is  intensely  fixed  to  a 
spot  of  the  abdomen,  at  other  times  it  is  vague  or  more  extend- 
ed.    The  patient  finds  most  relief,  by  laying  on  his  back,  with 
his  knees  drawn  up,  all  other  positions  being  extremely  painful. 
The  hypochondria  are  more  or  less  distended  ;  a  tumour,  answer- 
ing to  the  form  of  the  intestines,  may  be  sometimes  observed  ; 
the  stomach  swells,  and  becomes  to  a  certain  degree  tympanitic 
by  extricated  gases.    Hiccough,  nausea,  vomiting  succeed,  toge- 
ther with  great  anxiety;  respiration  hurried  and  painful ;  espe- 
cially during  inspiration.     These  symptoms  are  attended  some- 
times by  constipation,  at  other  times  by  diarrhoea. 

1858.  The  pulse  is  hard,  contracted,  and  frequent,  in  the  be- 

*  See  Puerperal  Fever.  Diseases  of  Females,  by  the  Author. 


PERITONITIS.  555 

ginning ;  and  towards  the  close,  when  the  disease  is  violent,  it 
becomes  so  frequent  as  scarcely  to  be  numbered.  The  face  is 
pale,  and  frequently  is  covered  by  a  cold  sweat;  and  by  and  by 
becomes  livid  and  agitated,  though  the  integrity  of  the  mind  is 
rarely  disturbed,  even  to  the  last.  The  extremities  become  cold 
and  clammy  ;  the  urine  high-coloured  and  very  scanty  ;  some- 
times depositing  a  lateritious  sediment. 

1859.  This  disease  must  ever  be  considered  as  one  of  danger ; 
but  the  suddenness,  and  degree  of  this,  will  in  some  measure  de- 
pend upon  the  force  of  the  causes,  the  susceptibility  of  the  parts 
concerned  ;  the  age,  the  sex,  the  temperament,  and  season  of  the 
year.     In  young,  vigorous,   and  plethoric  habits,  this  disease 
for  the  most  part,  is  more  violent,  painful,  and  rapid,  than  in 
people  advanced  in  years,  and  when  the  causes  act  slowly,  and 
moderately,  it  is  slower  in  its  march,  nor  is  it  marked  by  so  in- 
tense a  febrile  condition  of  the  system  ;  sometimes  it  is  only 
observable  towards  evening,   though  it  may  eventually  prove 
mortal. 

1860.  Peritonitis,  properly  so  called,  may  however  be  con- 
founded with  inflammations  to  which  the  substance  of  the  differ- 
ent viscera  of  the  abdomen  is  sometimes  liable;  as  with  the  in- 
flammation of  the  stomach,  the  intestines,  the  spleen,  the  liver, 
&c.  zmd  from  which  it  is  almost  impossible  to  distinguish  it;  but 
fortunately  a  mistake  of  this  kind  would  not  be  very  serious, 
perhaps  in  a  practical  sense,  as  the  curative  indications  would  be 
the  same. 

1861.  This  disease  is  sometimes  so  insidious  and  apparently 
so  mild,  that  the  inexperienced  practitioner  may  be  led  into  an 
error  in  prognostic.  As  a  general  rule,  where  the  disease  is  as- 
certained, the  issue  should  always  be  dreaded,  though  it  is  not 
necessarily  fatal.     Where  the  constitution  is  good,  the  proper 
remedies  early  applied,  and  faithfully  pursued,  the  disease  may 
be  overcome;  but  in  feeble  constitutions,  where  important  time 
has  been  lost,  or  the  ease  injudiciously  treated,  it  is  but  too  cer- 
tain to  prove  fatal. 

1862.  Peritonitis  runs  its  course  with  great  rapidity  in  gene- 
ral, especially  in  females  after  delivery.     For  the  most  part  it 
terminates  from  the  fifth  to  the  tenth  day,  and  rarely  exceeding 
fourteen  days.     It  may,  like  all  other  inflammations,  terminate 
by  resolution,  effusion,  by  gangrene,  or  by  becoming  chronic. 

1863.  Bichat  informs  us,  that  the  dissections  of  persons  dying 
from  acute  peritonitis,  prove  that  the  peritoneum  may  be  in- 
flamed through  its  whole  extent,  or  in  portions,  without  the  or- 
gans lying  beneath  it  being  affected.  In  many  instances  the  mus- 
cular coat  of  the  stomach  and  intestines  have  been  found  sound, 
when  this  membrane  itself  has  been  in  a  state  of  absolute  gan- 


556  PERITONITIS. 

grene.*  And  as  a  general  rule,  the  traces  of  inflammation  are 
evident  in  proportion  as  the  disease  may  have  been  more  ad- 
vanced and  more  intense.  Sometimes  the  vessels  are  highly  in- 
jected and  red ;  while  at  other  times,  the  redness  is  scarcely  per- 
ceptible ;  the  blood  having  escaped  by  the  collateral  branches. 

1864.  Dissections  prove  the  highly  phlogosed  state  of  the 
peritoneum  in  peritonitis,  and  thus  points  out  the  mode  of  cure. 
The  first  step  is  to  diminish  the  quantity  of  blood,  by  bleeding 
liberally  from  the  arm,  and  this  to  be  repeated  if  the  symptoms 
do  not  abate.     Besides  the  general  bleeding,  local  bleedings  by 
leeches  must  be  practised,  and  this  as  near  the  seat  of  pain, 
when  it  locates  itself,  as  possible,  or  when  it  does  not,  and  the 
pain  and  tenderness  is  general,  they  may  be  more  diffused  over 
the  abdomen — the  quantity  to  be  drawn,  will  always  depend  up- 
on the  activity  of  the  disease,  and  force  of  the  arterial  system; 
from  six  to  eight  ounces  may  be  considered  as  a  common  quan- 
tity, but  must  be  repeated  if  the  symptoms  persevere,  and  this 
in  quantities  adapted  to  the  state  of  the  system. 

1865.  The  bowels  should  be  kept  open  by  castor  oil,  or  weak 
solutions  of  the  neutral  salts,  but  not  actively  purged.  All  pres- 
sure should  be  removed  from  the  abdomen  ;  and  the  most  abso- 
late  antiphlogistic  regimen  enjoined,  (see  par.  214,  &c.)  the  drinks 
should  be  gum  water,  barley  water,  flaxseed  tea,  apple  water, 
thin  lemonade,  &c.     The  patient  should  be  kept  as  still  as  possi- 
ble, as  motion  always  hurries  the  circulation,  and  thus  increases 
the  mischief.     Some  recommend  warm  fomentations,  but  we 
have  never  witnessed  any  marked  advantage  from  them,  and 
they  are  liable  to  all  the  objections  we  have  made  against  their 
use  in  puerperal  fever.     Others  have  thought  much  advantage 
was  derived  from  cold  applications  to  the  abdomen,  when  the 
system  is  labouring  under  high  excitement — but  of  this  we  can 
say  nothing  from  our  own  experience.   One  rule  however  should 
be  observed  in  the  temperature  of  the  drinks  of  the  patient;  to 
give  them  rather  less  than  lukewarm  or  cold,  according  to  the 

*  Notwithstanding  this  declaration,  it  would  appear  that  the  serous  mem- 
brane of  the  stomach  is  less  liable  to  acute  inflammation  than  other  portions  of 
the  peritoneum,  if  the  observations  of  Dr.  Abercrombie  be  correct;  for  he  de- 
clares, that  "in  cases  of  very  extensive  peritonitis  the  peritoneal  coat  of  the 
stomach  is  sometimes  affected;  but  even  this  is  rare,  and  a  case  of  pure  inflam- 
mation of  the  peritoneal  coat  of  the  stomach  I  have  never  seen,  and  do  not  find 
described  by  any  writer.  Dr.  Armstrong,  in  the  first  fasciculus  of  his  work  on 
the  Morbid  Anatomy  of  the  Stomach  and  Bowels,  gives  a  plate  representing 
inflammatory  deposition  on  the  peritoneal  coat  of  the  stomach;  but  no  account 
is  given  of  the  case  from  which  it  was  taken,  so  that  it  does  not  appear  whe- 
ther it  was  an  example  of  pure  idiopathic  gastritis,  or  whether  the  appearancr 
occurred  in  connexion  with  extensive  peritonitis." — Diseases  of  the  Stomach, 
p.  13. 


PERITONITIS. 


557 


degree  of  excitement  or  the   symptoms.     Blisters  to  the  ex- 
tremities are  sometimes  useful.* 

Chronic  Peritonitis. 

1666.  Should  the  patient  live  with  an  acute  peritonitis  beyond 
the  fifteenth  or  twentieth  day,  and  have  an  abatement  of  the  se- 
vere symptoms,  the  inflammation  may  assume  a  chronic,  or  sub- 
acute  form ;  hence,  the  acute  is  not  an  unfrequent  cause  of  the 
latter  form  of  this  disease.  We  must  not,  however,  regard  this 
as  the  only  cause,  for  it  sometimes  makes  its  appearance  slowly 
and  silently,  in  consequence  of  slight,  but  long-continued  irrita- 
tion, of  either  a  mechanical,  or  even  a  chemical  cause.  Thus, 
workmen  whose  employments  require  long  and  steady  pressure 
upon  the  abdomen,  as  shoemakers,  coopers,  tailors,  &c.  are  per- 
haps more  disposed  to  this  condition,  than  those  whose  labours 
require  no  such  exertion  of  the  abdomen.  But  above  all,  if  the 
observations  of  Broussais  are  correct,  and  we  have  every  reason 
to  believe  they  are,  soldiers  are  more  liable  to  chronic  peritonitis 
than  any  other  class  of  people.  This  arises,  he  supposes,  from 
several  causes ;  as  exposure  to  cold  and  moisture ;  to  their  fre- 
quent bivouacings ;  the  cold  stage  of  intermittents.  Great  age ; 
feebleness  of  constitution ;  effusions  into  the  cavity  of  the  abdo- 
men ;  may  also  be  causes. 

1867.  The  attack  of  this  disease  is  always  insidious,  and,  in 
some  instances,  remains  for  a  long  time  concealed,  as  its  invasion 
cannot  be  recognised  by  any  distinctly  marked  symptom.     It  is, 
however,  to  be  suspected,  or  perhaps  detected,  if  by  an  exami- 
nation of  the  patient,  we  find  he  complains  of  a  long-standing 
tenderness  of  the  abdomen ;  or  of  one  which  can  at  times  be  dis- 
covered by  pretty  firm  pressure ;  for  it  is  the  character  of  chro- 
nic peritonitis,  to  be  attended  by  a  dull,  obtuse  pain,  and  not  by 
an  acute  sensation.     Indeed,  we  may  declare  that  there  is  some- 
thing peculiar  in  the  inflammation  of  the  serous  membranes, 
since  it  is  not  always  attended  by  pain ;  this  is  remarkably  the 
case  with  the  pleura  sometimes,  as  we  have  had  occasion  to  re- 
mark when  treating  on  pneumonia,  as  it  has  proceeded  even  to 
suppuration,  without  the  patient  complaining  of  pain. 

1868.  On  this  account,  we  should  be  upon  our  guard,  after  the 
active  stage  of  the  acute  form  of  this  disease  has  passed  away, 
that  it  leaves  not  behind  a  chronic,  or  concealed  inflammation. 
We  must  not  always  rest  satisfied  with  the  mere  absence  of  suf- 
fering.    Sometimes,  however,  the  disease  declares  itself  openly 

*  For  more  particular  details,  see  Puerperal  Fever.  Diseases  of  Females,  by 
the  Author. 


558  PERITONITIS. 

by  the  presence  of  a  fixed  pain,  resembling  the  stretching  of  a 
very  tender  part;  this  is  not  attended  by  either  heat  or  throbbing; 
the  seat  of  the  pain  is  generally  in  the  epigastrium;  and  is  sure 
almost  to  be  aggravated  by  jolts,  or  violent  motion  of  any  kind, 
as  coughing,  sneezing,  &c. 

1869.  A  slight  swelling  may  be  observed  in  the  belly,  which 
is  a  little  elastic,  and  which  increases  towards  evening.     The 
appetite  does  not  fail  in  general,  and  the  digestion  is  not  de- 
ranged.    Vomiting  sometimes  attends;  in  the  former  state  of 
things,  it  is  thought  that  the  peritoneum  covering  the  stomach 
is  not  implicated  in  the  inflammation ;  while  in  the  latter,  it  is 
believed  that  it  suffers.  Broussais  speaks  of  a  feeling  in  the  belly 
which  resembles  a  ball  turning  round ;  and  which  has  a  tendency 
to  ascend  to  the  throat;  for  which  he  accounts,  by  supposing  it 
is  formed  by  a  portion  of  the  intestines,  and  the  engorged  mesen- 
teric  glands  becoming  agglutinated. 

1870.  One  of  the  most  remarkable  facts  connected  with  this 
disease,  is  the  natural  beat  of  the  pulse  in  the  morning ;  but  there 
is  a  small  increase  in  frequency  towards  evening;  at  which  time 
a  slight  augmentation  of  heat  may  be  observed,  and  the  cheeks  to 
redden;  the  breathing  is  a  little  difficult,  and  cough  upon  lying 
down,  giving  rise  to  a  suspicion,  that  there  may  be  already  some 
effusion  in  the  abdomen.     This  suspicion  will  almost  amount  to 
certainty,  if  there  be  joined  to  these  symptoms  oedema,  and  a 
sparing  secretion  of  urine.    Constipation  sometimes  accompanies 
this  complaint;  and  diarrhoea  is  pretty  sure  to  supervene  towards 
the  fatal  close  of  it.     Slow  as  this  disease  is  in  its  march,  it  is, 
nevertheless,  when  it  has  arrived  to  the  condition  just  stated, 
sure  to  prove  fatal. 

1871.  But  what  can  we  Say  encouraging  of  the  treatment  of 
this  disease?  we  fear  nothing — if  the  inflammation  has  absolutely 
ceased  to  possess  an  acute  form.     Yet  it  would  appear  wrong  to 
abandon  the  patient  altogether  to  the  efforts  of  nature ;  first,  be- 
cause, however  hopeless  apparently  the  case  may  appear,  it  is 
not  perhaps  absolutely  beyond  the  possibility  of  recovery;  se- 
cond, because,  patients  do  sometimes  recover  under  the  most 
forlorn   circumstances,   by  the  persevering  use  of  judiciously 
adopted  measures.     Therefore,  we  should  exert  our  energies  in 
favour  of  the  sufferer,  however  desperate  the  case  may  appear. 

1872.  We  well  recollect  a  case,  in  which  there  was  nothing 
to  hope,  yet  this  patient  recovered ;  and  we  attributed  the  reco- 
very to  the  free  use  of  the  spirit  of  turpentine.     In  this  we  may 
have  been  mistaken — it  might  have  been,  and  perhaps  was,  mere 
coincidence;  yet  the  patient  appeared  to  mend  immediately  after 
its  exhibition  by  the  mouth,  and  its  liberal  external  application. 


ICTERUS,  OR    JAUNDICE.  559 

Pain  was  quickly  diminished;  the  diarrhoea  soon  abated;  effusion 
was  arrested ;  and  the  patient  recovered. 

1873.  In  cases  of  this  kind,  therefore,  we  would  recommend 
the  trial  of  this  substance  in  forty  drop  doses  every  two  hours, 
gradually  increasing  it  if  the  stomach  become  reconciled  to  it. 
At  the  same  time  the  abdomen  should  be  bathed  with  it  morning 
and  evening,  until  it  irritate  the  skin  sufficiently;  and  when  this 
subsides,  to  renew  it  by  fresh  applications  of  the  turpentine. 
Blisters  to  the  thighs  perhaps  may  be  useful  at  the  same  time. 
Should  these  fail,  we  know  nothing  beside  to  recommend./ 

SECT.  II. — ICTERUS,  OR  JAUNDICE. 

1874.  Jaundice  may  be  defined,  that  affection,  in  which  the 
white  portions  of  the  eyes  are  suffused  with  yellow;  in  which 
the  urine  is  of  a  dark  saffron  hue,  and  the  alvine  excretions  are 
whitish  or  clay-coloured.     There  is  scarcely  any  other  disease 
in  the  whole  range  of  medical  nomenclature,  that  has  received 
so  many  gratuitous  titles  as  the  disease  in  question — owing, 
principally  to  the  hypothetical  views  of  its  cause ;  but  we  shall 
not  name  them,  as  we  shall  confine  ourselves  to  the  two,  at  the 
head  of  the  chapter. 

1875.  This  disease  was  known  to  Hippocrates,  and  to  all  the 
writers  since  his  period ;  but  we  are  indebted  to  the  moderns, 
for  a  satisfactory  history  of  this  oftentimes  persevering,  and 
sometimes  unconquerable,  disease. 

1876.  It  has  been  classed  variously  by  different  nosologists, 
and  by  practical  writers — thus  Sauvage,  Sagar,  Linnsus,  Vogel, 
Cullen,  Macbride,  Darwin,  &c.  place  it  among  the  cachexia ;  but 
no  two  of  these  agree  as  regards  the  Order,  in  which  it  should 
stand;  however  we  shall  not  stop  to  inquire  into  the  propriety 
of  either  of  the  situations  it  is  placed  in  by  these  respective  au- 
thors, as  its  causes,  and  the  condition  of  the  system  when  it 
takes  place,  are  sufficiently  varied,  to  prevent  any  regular  posi- 
tion in  nosological  arrangement.     Indeed  by  some,  as  Pinel,  the 
disease  is  considered  in  the  adult,  as  always  symptomatic ;  in 
this  he  is  sustained  by  many  others,  since  he  wrote  his  "  Noso- 
graphie  Philosophique."     While  the  author  of  the  article  in 
"Diet,  des  Sciences  Med."  on  this  subject,  makes  it  both  symp- 
tomatic and  idiopathic,  and  we  believe   with  entire  propriety. 
He  therefore  proposes  to  distinguish  these  species  by  affixing  the 
term  icterus,  to  the  idiopathic,  and  jaundice,  to  the  symptoma- 
tic.    But  we  are  of  opinion,  there  is  no  very  great  benefit  to  be 
derived  from  these  distinctions,  in  a  practical  point  of  view,  as  it 
will  not  be  found  an  easy  matter  at  the  bed-side,  to  determine 
the  absolute  nature  of  the  disease. 


560  ICTERUS,  OR    JAUNDICE. 


Causes. 

1877.  It  is  admitted  by  every  authority,  that  this  disease  may 
be  produced  by  a  great  variety  of  causes;  as  a  plethoric,  or  an  en- 
gorged state  of  the  liver  itself;  by  an  inflammation  of  it,  either 
acute  or  chronic  ;  by  an  abscess  formed  within   it ;  chronic,  or 
organic  affections  of  it ;  by  a  compression  exerted  upon  the  bi- 
liary ducts  from  pregnancy  ;  over-distention  of  the  stomach  and 
bowels ;  organic  derangements  in  the  organs  in  the  vicinity  of 
the  liver;  from  repelled  eruptions,  or  metastasis;  from   biliary 
calculi ;  from  wounds,  &c.  &c. 

1878.  Early  life,  or  extreme  age,  are  less  disposed  to  jaun- 
dice, than  the  period  comprehended  between  the  age  of  twenty- 
five  and  sixty.     Agreeably  to  our  own  observations,  females  are 
more  obnoxious  than  males,  to  this  disease.     Saunders  is  also  of 
this  opinion ;  especially  among  such  as  are  of  sedentary  habits. 
Some  declare  a  belief  in  the  bilious  temperament,  as  especially 
obnoxious  to  jaundice ;  but  this  is  by  no  means  proved,  as  we 
have  just  stated,  that  females  are  more  liable  to  it  than  males  ; 
and  the  female  constitutional  character  partakes  more  of  the  san- 
guine and  lymphatic,  than  the  bilious  temperament. 

1879.  Transient  errors  in  diet,  have  been  said  to  cause  jaun- 
dice— this  may  have  happened;  but  we  are  of  opinion,  these  are 
rare  causes  of  this  complaint.   And  even  the  exposure  for  a  long 
time  to   atmospherical  vicissitudes,  or  to  long-continued  heat, 
rarely  if  ever  occasion  the  idiopathic  jaundice.     Excesses  in  eat- 
ing and  drinking  if  long  continued,  may  produce  this  disease; 
especially  if  ardent  liquors  be  freely  indulged  in.     But  when 
jaundice  follows  the  causes  enumerated,  it  is  owing  to  the  liver 
itself  being  in  a  morbid  condition;  and  thus  it  becomes  a  symp- 
tomatic affection.     We  have  never  ourselves  met  with  a  case  of 
jaundice  from  the  suppression  of  any  evacuation,  either  natural 
or  accidental ;  though  authors  relate  instances  to  this  effect.   We 
have  however  witnessed  two  instances  of  temporary  jaundice, 
from  strong  passion  or  emotion  of  the  mind.*     Hoffman  relates 
a  case  where  jaundice  followed  every  excess  in  coition. 

1880.  But  the  most  frequent  causes  of  this  complaint,  reside 
either  in  the  liver  itself,  its  appurtenances,  or  in  their  immediate 
vicinity — as  a  plethoric,  or  inflammatory  condition   of  this  or- 
gan— some  obstruction  in  its  ducts,  from  inflammation,  from  cal- 
culi, or  viscid  secretions;  tumours  in  the  duodenum,  stomach, 

*  In  the  "  Dublin  Hospital  Reports,"  Vol.  III.  Art.  6th,  is  an  account  by  Dr. 
Marsh,  of  a  young  woman,  in  the  Lock  Hospital,  who  was  suddenly  informed 
of  the  death  of  an  uncle  who  alone  of  her  relatives  had  been  kind  to  her,  be- 
coming universally  jaundiced. 


ICTERUS,  OR    JAUNDICE.  561 

pylorus,  pancreas,  &c.  Scirrhus,  ulcers,  dropsy,  and  hydatids, 
of  the  liver,  have  all  been  accused,  and  perhaps  justly,  in  pro-, 
ducingjaundice. 

1881.  There  is  scarcely  less  diversity  of  opinion  among  au- 
thors, as  regards  the  condition  of  the  circulating  fluids,  than  in 
the  assigned  causes  of  this  disease.  One  supposes,  that  the  con- 
stitution of  the  blood  is  changed  ;  and  that  the  yellowness  which 
characterizes  this  disease,  is  not  owing  to  the  presence  of  absorb- 
ed bile.  Galen  was  of  opinion,  that  the  bile  existed  formally  in 
the  blood;  and  that  a  secretion  by  the  liver,  was  not  necessary 
to  its  formation.  Stoll  and  some  others  were  of  opinion,  that 
the  condition  of  the  cellular  membrane  has  been  so  modified  as 
to  secrete  a  yellow  matter,  analogous  to  bile;  and  thus  tinge  all 
the  organs  of  the  body.  We  do  not  think  however,  when  this 
condition  of  the  cellular  membrane  takes  place  so  as  to  give  rise 
to  this  change  of  colour  of  the  skin,  &c.  that  the  colouring  ma- 
terial  is  bile,  or  any  way  analogous  to  bile,  save  in  colour  ;  for 
this  coloration  takes  place  in  yellow  fever;  and  this,  when  nei- 
ther the  secretion  of  urine,  or  sweat,  or  of  tears,  partake  of  this 
change.  The  same  phenomenon  and  most  probably  from  a  si- 
milar cause,  takes  place  from  the  bites  of  certain  poisonous  ani- 
mals ;  and  we  have  lately  seen  in  a  child  of  four  weeks  old,  an 
intense  yellowness  spread  itself  through  the  whole  visible  extent 
of  the  cellular  membrane  in  the  course  of  a  few  hours,  where 
there  did  not  exist  any  other  evidence  of  jaundice — for  the  stools 
were  natural,  and  the  urine  pale.  This  affection  went  off  in  the 
course  of  eight  or  ten  days,  without  the  employment  of  any  re- 
medy save  a  very  weak  solution  of  soda;  or  by  any  discharge, 
either  by  the  skin,  bowels,  or  kidneys,  that  could  be  looked 
upon  as  critical. 

1882.  It  is  proper  then  to  distinguish  between  the  yellow  co- 
lour which  is  occasioned  by  the  colouring  matter  of  the  bile  being 
absorbed  from  the  liver  itself,  or  from  the  gall-bladder,  or  by  its 
extrication  from  th»  mass  of  blood,  by  some  unknown  agency, 
and  that  yellowness,  which  accompanies  yellow  fever,  the  bites 
of  certain  reptiles;  or  as  it  takes  place  sometimes  from  causes 
which  elude  our  investigations  in  young  children,  as  just  stated. 
The  urine,  the  sweat,  the  tears,  and  the  alvine  discharges,  are 
always  to  be  appealed  to,  to  settle  these  differences — should  all 
the  first  named  secretions  be  free  from  the  saffron  tint,  and  the 
excretion  last  named  be  found  to  possess  its  natural  hue,  we 
should  not  call  the  affection  jaundice.     But  on  the  other  hand, 
should  the  secretions  just  named  be  coloured,  and  the  stools  be 
free  from  it,  or  clay-coloured,  we  may  with  certainty  pronounce 
the  disease  to  be  jaundice,  either  idiopathic,  or  symptomatic. 

1883.  That  there  is  much  cavil  as  to  the  constituent  parts  of 

71 


562  ICTERUS,  OK  JAUNDICE. 

* 

the  urine  of  jaundiced  patients,  we  admit;  and  that  the  analyses 
of  this  fluid,  have  given  different  results  in  the  experiments  of 
several  very  able  chemists  who  have  undertaken  them,  we  have 
no  doubt.  Yet  we  are  of  opinion,  that  as  bile  has  been  detected 
occasionally  in  the  urine  of  icteric  patients;  and  that  it  is  present 
in  most  instances,  though  the  chemist  is  not  able  at  all  times,  to 
detect  it,  we  have  a  right  to  insist  upon  its  being  the  cause  of  colour 
throughout  the  system,  and  of  all  its  fluids.  Orfila  in  his  re- 
searches upon  this  subject,  concludes,  that  the  urine  of  icterics 
contains  bile;  though  it  is  impossible  in  some  cases  he  says  to 
detect  it.  Fourcroy  and  Vauquelin  are  of  the  same  opinion  ;  while 
Thenard  absolutely  denies  it — he  says,  the  proofs  offered  in  fa- 
vour of  the  presence  of  bile  in  the  blood,  takes  too  much  for 
granted  to  be  admitted.  But  do  not  the  well-conducted  and  in- 
genious experiments  of  Tiedemann  and  Gmelin,  render  it  more 
than  probable,  nay  certain,  that  the  bile  enters  the  circulation, 
whenever  the  common  duct  is  obstructed  ?  for  they  found  on  the 
third  day  after  a  ligature  had  been  passed  around  the  ductus 
choledocus,  the  eyes  of  the  animal  became  yellow,  and  the  urine 
highly  tinged;  and  in  which,  they  detected  by  chemical  tests, 
bile — it  is  therefore  in  vain  to  deny  its  presence  in  the  circula- 
lation,  under  certain  circumstances.  For  the  trite  objection,  that 
bile  is  too  acrid  a  substance  to  be  taken  up  by  the  absorbents, 
is  not  of  the  slightest  value  ;  since  Desyeux,  Clarion,  Orfila,  &c. 
&c.  have  absolutely  detected  it  in  the  urine  of  jaundiced  patients. 
Nor  do  the  instances  of  fatal  jaundice,  in  which  there  was  found 
no  organic  lesion  of  the  liver,  or  ducts,  prove  that  an  obstruction 
in  the  common  duct  is  not  necessary  to  the  formation  of  this  dis- 
ease, by  giving  opportunity  for  the  absorption  of  bile  ;  since  it 
is  generally  agreed,  that  the  biliary  ducts  are  liable  to  spasm,  and 
may  thus,  under  this  state,  become  a  cause  of  jaundice; — of  this 
kind  is,  most  probably  the  jaundice  which  follows  an  hysterical 
paroxysm,  and  passion  and  emotions  of  the  mind. 

1884.  But  why  should  the  absorption  of  bile  into  the  blood 
be  BO  stoutly  denied  upon  the  mere  faith  of  certain  chemical  ex- 
periments, that  failed  to  detect  it ;  or  even  more  frivolous  rea- 
sons, when  it  has  been  absolutely  found  by  other  experimenters? 
especially,  as  we  have  strong  analogies  from  the  habits,  if  we 
may  so  term  them,  of  other  portions  of  the  body.  Are  not  other 
secreted  fluids  made  to  reenter  the  system  by  means  of  the  ab- 
sorbents? Has  not  the  urinous  smell  been  detected  in  the  breath, 
and  perspiration,  of  those  who  laboured  under  a  retention  of  this 
fluid  ?  Has  not  the  milk  from  the  breasts  been  frequently  ab- 
sorbed, when  it  has  been  suffered  to  remain  stagnant  in  the  lac- 
tiferous vessels?  Has  not  the  semen  in  very  continent  men  been 
absorbed,  and  its  odour  detected  in  the  perspiration?  Has  not 


ICTERUS,  OR    JAUNDICE.  563 

pus  from  even  pretty  large  abscesses  been  taken  into  the  sys- 
tem?* Then  where  is  the  difficulty  in  believing  the  same  to  hap- 
pen from  the  biliary  vessels,  the  gall-bladder,  or  even  from  the 
ducts,  when  the  latter  have  been  obstructed  ?  At  all  events,  we 
are  every  way  certain,  that  the  colouring  mailer  of  the  bile  is 
constantly  absorbed  in  jaundice,  if  it  be  denied  on  the  faith  of 
chemical  experiments,  that  the  other  portions  of  this  fluid  do  not 
enter  the  circulating  mass ;  and  that  we  are  forced  to  the  belief, 
that  the  principal  phenomena  of  this  disease,  if  not  its  very  seat, 
arise  from  the  liver.  Or  in  other  words,  we  believe,  that  for  the 
existence  of  jaundice,  it  is  essential  that  the  liver  be  in  an  anor- 
mal  state. 

Symptoms. 

1885.  It  very  often  happens,  that  jaundice  is  not' preceded  by 
any  very  marked  precursive  phenomena,  that  are  independent  of 
some  local  affection  that  may  give  rise  to  such  symptoms.    It  is 
occasionally,  however,  ushered  in  by  feeble  pyrexia;  a  sense  of 
heaviness  or  weight  about  the  precordia,  and  some  dyspeptic 
sensations.     But  at  other  times,  it  is  found  to  follow  the  deter- 
mining cause  very  quickly.     This  especially  happens,  when  a 
moral  cause  is  capable  of  producing  it;  as  after  violent  passions, 
or  emotions  of  the  mind ;  after  hysteria ;  after  the  bite  of  certain 
animals  if  this  be  admitted  as  genuine  jaundice;  or  where  the 
common  duct  becomes  obstructed  by  a  gall-stone.     In  children, 
it  is  almost  always  induced  suddenly;  as  for  the  most  part, 
children  in  the  month,  are  more  obnoxious  to  jaundice,  than  in 
more  advanced  childhood. 

1886.  The  eyes  for  the  most  part,  and  especially  their  internal 
angles,  first  becomes  tinged :  and  then  in  succession,  the  whole 
of  the  white  portions,  and  this  sometimes  before  the  urine  be- 
trays any  evidence  of  absorbed  bile.  From  the  eyes,  it  gradually 
spreads  itself  upon  the  temples,  forehead,  eyelids,  lips,  nose;  in 
a  word,  the  whole  face  becomes  tinged,  first  with  a  pale,  and 
soon  after  a  deep  yellow.  Certain  portions  of  the  face,  however, 
are  longer  free  from  the  colouring  matter  than  others — as  the  ex- 
tremity of  the  nose,  the  chin,  and  the  cheeks.    The  lips  become 
dark,  sometimes  even  to  lividity.   The  neck  and  forepart  of  the 

*  In  the  year  of  1792,  we  witnessed  the  entire  absorption  of  the  pus  from  a 
very  large  mammary  abscess,  which  we  were  about  to  pierce;  but  upon  exa- 
mining our  pocket-case,  we  could  not  find  a  lancet,  and  in  consequence  de- 
ferred the  puncture  until  the  next  day.  But  upon  visiting  our  patient,  we 
found  the  tumour  so  much  diminished,  that  we  were  instantly  inspired  with  a 
hope,  that  the  whole  of  the  pus  would  be  absorbed — this  accordingly  happen- 
ed in  the  course  of  a  very  few  days. 


564  ICTERUS,    OR    JAUNDICE. 

thorax  eminently  partake  of  the  yellow  tinge,  while  certain  other 
portions  retain  nearly,  if  not  entirely,  their  natural  tone. 

1887.  The  skin  is  oftentimes  dry,  hard,  and  warm.     The  na- 
tural functions  of  this  covering,  are  altogether  suspended,  or  but 
very  moderately  exercised.     At  other  times,  it  pours  out  sweat 
in  abundance;  and  this  highly  tinged  with  the  icteric  colouring, 
especially  in  such  parts  as  are  more  warmly  protected,  as  in  the 
armpits,  groins,  &c.     The  patient  is  sometimes  incommoded  by 
an  extensive  itching,  which  requires  severe  scratching  to  relieve, 
especially  during  the  night;  and  occasionally,  theskin  desquamates. 

1888.  Upon  the  first  appearance  of  the  disease,  the  urine  par- 
takes of  the  general  yellowness;  it  however  assumes  different 
tones  of  yellow,  from  the  light  saffron  to  the  dark  beer  colour. 
It  deposits  either  a  lateritious,  or  a  wine  lees,  sediment. 

1889.  The  alvine  excretions,  as  above  stated,  are  grayish  or 
clay-coloured^-the  bowels  slow,  and  render  their  contents  tar- 
dily, and  in  small  quantities;  but  this  is  not  uniformly  so,  as  I 
have  upon  several  occasions  seen  the  bowels  moved  even  to  a 
brisk  diarrhoea;  and  upon  three  occasions,  the  quantity  rendered 
was  enormous;  and  so  light  as  to  float  upon  the  surface  of  the 
urine  or  other  watery  discharges.     In  these  cases  the  odour  was 
powerful,  and  peculiarly  disagreeable. 

1890.  The  head  also  suffers  in  this  disease — sometimes  vio- 
lently pained,  at  intervals;  at  other  times  the  pain  dull,  perse- 
vering, and  harassing — the  temper  becomes  soured;  and  the  pa- 
tient, under  the  gravest  forms  of  this  disease,  is  even  sad,  and 
melancholy.     The  tongue  is  furred ;  and  the  mouth  and  teeth 
become  encrusted  with  a  yellow  covering,  which  it  is  difficult  to 
remove.  The  taste  becomes  impaired  in  its  discriminating  powers; 
for  every  thing  to  it  is  bitter;  and  this  even  when  it  is  not  exer- 
cised upon  food.     Thirst,  with  a  desire  for  subacid  drinks,  is 
sometimes  importunate — the  appetite  is  irregular  and  wayward — 
at  one  moment  disgusted  with  every  thing,  at  others  voraciously 
craving. 

1891.  The  stomach  for  the  most  part  is  flatulent,  which  gives 
rise  to  disagreeable  eructations — in  one  patient,  they  could  be 
smelt  at  a  considerable  distance.     Sometimes  vomiting  ensues, 
and  nausea  is  very  frequently  present.  A  pain  is  sometimes  felt 
in  the  direction  of  the  ductus  choledocus,  and  extending  itself 
to  the  epigastrium.     A  pain  is  also  felt  in  the  hepatic  region, 
which  is  sometimes  tumid  and  tender  to  the  touch.    Colic  is  not 
unfrequent;  but  is  especially  severe,  when  the  common  duct  is 
obstructed  by  a  gall-stone.     The  respiration  is  but  little  affected 
in  the  milder  forms  of  this  disease;  but  when  a  tendency  to  effu- 
sion shows  itself,  it  becomes  short,  oppressed,  and  hurried;  espe- 
cially upon  going  up  stairs,  or  making  any  other  exertion. 


ICTERUS,   OR    JAUNDICE.  565 

1892.  The  pulse  is  rarely  much  affected  during  the  mild  stage 
of  jaundice — for  the  most  part,  it  is  slower  than  natural;  with 
more  than  ordinary  tenuity  and  hardness;  and  does  not  become 
mu-ch  quickened,  unless  local  inflammation  accompany  the  dis- 
ease; when  this  happens,  the  ordinary  phenomena  of  pyrexia 
show  themselves. 

1893.  The  patient  gradually  becomes  weaker  as  the  disease 
progresses,  and  manifests  a  very  decided  aversion  to  exercise  or 
motion.     And  according  to  Portal,  the  arms,  but  especially  the 
right,  becomes  numbed.  Haemorrhoids  frequently  establish  them- 
selves during  this  disease;  and  sometimes  they  are  regarded  crir 
tical ;  as  is  also  bleedings  from  the  nose.  Monro,  however,  says 
this  is  sometimes  a  fatal  symptom.     It  proved  so  in  a  very  few 
hours,  in  the  only  case  we  have  witnessed.     It  was  an  elderly 
lady,  who  had  laboured  under  jaundice  for  some  months,  and 
while  walking  across  the  floor>  was  seized  with  epistaxis.     The 
blood  flowed  in  such  a  torrent  as  to  defy  opposition,  and  the 
patient  died  exsanguined,  in  a  very  few  hours. 

1894.  Like  every  other  disease,  jaundice  may  terminate,  in 
health,  in  other  diseases,  or  in  death.     It  may  be  complicated, 
with  dropsy,  or  other  affections ;  and  this  mostly  of  the  scirrhus 
kind,  of  almost  any  of  the  abdominal  viscera — but  most  frequently 
of  the  liver — 'hence,  it  may  be  associated  with  melana. 

Diagnosis. 

1895.  The  characters,  or  phenomena  of  jaundice  as  laid  down 
above,  are  so  truly  characteristic,  that  we  need  only  refer  to  what 
was  said  in  par.  1874,  to  be  in  possession  of  every  thing  that  dis- 
tinguishes it.     We  have  denied  that  the  yellowness  of  "  yellow 
fever"  proceeds  from  the  colouring  matter  of  bile;  for  it  did  not 
tinge  the  whites  of  the  eyes,  as  in  jaundice ;  nor  is  yellow  fever 
attended  by  the  clay-coloured  stools,  nor  always  with  the  deep- 
toned,  or  beer-coloured  urine,  of  icterics — besides,  jaundice  is 
not  generally  accompanied  by  pyrexia.  It  is  true,  when  jaundice 
is  decidedly  symptomatic,  which  as  we  have  already  observed 
ia  frequently  the  case,  the  fever  which  may  complicate  it,  is  sure 
to  belong  to  the  idiopathic  affection. 

Prognosis. 

1896.  As  a  general  rule  the  prognosis  of  the  idiopathic  jaun- 
dice is  more  favourable  than  that  of  the  symptomatic;  for  in  the 
latter  there  are  ajways  two  diseases  to  contend  against — but  in 
both  it  will  vary,  from  age,  sex,  idiosyncrasy,  and  general  strength 
of  constitution.     The  nature  of  the  remote  cause  should  also  be 


566  ICTERUS,   OR    JAUNDICE. 

taken  into  consideration ;  for  if  this  be  a  manageable  disease,  the 
sympathetic  affection  will  yield  the  more  readily — hence,  the 
jaundice  of  pregnant  women  will  disappear  after  delivery,  &c. 
so  that,  from  spasm  of  the  duct,  or  glutinous  obstructions  of  the 
extremity  of  the  duct,  or  a  preternatural  viscidity  of  the  bile  it- 
self. As  regards  age,  we  almost  constantly  find  the  disease  is 
less  obstinate,  caeteris  paribus,  in  young  people.  Indeed  some 
have  looked  upon  jaundice  as  always  fatal  in  old  people,  and 
especially  in  old  women.  In  such  as  are  disposed  to  large  secre- 
tions of  bile,  or  have,  from  peculiarity  of  constitution,  a  tendency 
to  biliary  concretions,  the  disease  is  constantly  found  to  be  of 
more  difficult  management.  Though  in  some  instances  of  this 
disease  caused  by  biliary  concretions,  the  icteric  symptoms  have 
suddenly  disappeared,  though  attended  by  severe  suffering  pre- 
viously. In  these  cases  it  is  presumable,  the  gall-stones  were 
but  of  moderate  size,  or  that  the  duct  suffered  itself  to  be  dilated, 
without  long  or  very  intense  pain.  Instances  have  occurred,  in 
which  gall-stones  have  passed  of  a  size  much  larger  than  we 
would  have  supposed  the  duct  capable  of  transmitting — in  one 
instance,  we  saw  seven  pass  of  the  size  of  tamarind  stones — a 
size  much  larger  than  is  generally  believed  can  pass.  Dr.  Gre- 
gory, however,  goes  much  beyond  this — he  tells  us  he  saw  one 
transmitted,  that  weighed  six  drachms.  It  is  generally  fatal  to 
hard  drinkers ;  as  in  such,  the  liver  becomes  highly  diseased,  or 
torpid. 

1897.  In  the  absence  of  any  general  disturbance  in  the  vital 
functions,  jaundice  may  be  looked  upon  as  a  manageable  com- 
plaint, provided  it  does  not  supervene  on  an  acute  or  chronic 
disease,  in  which  the  strength  has  been  much  exhausted.   If  the 
stools  assume  a  bilious  appearance,  the  urine  become  paler  and 
less  loaded,  and  the  skin  soft,  we  have  reason  to  hope  the  disease 
is  abating.  In  proportion,  however,  as  this  disease  may  be  com- 
plicated with  any  other  unmanageable  disease,  will  be  the  uncer- 
tainty of  its  cure — as  with  dropsy,  scirrhus  liver,  &c.     So  also, 
when  the  perspiration  tinges  the  linen  of  the  patient. 

Appearances  on  Dissection. 

1898.  There  is  some  difficulty  upon  opening  the  body  of  a 
jaundice  patient,  to  determine  what  changes  absolutely  belongs 
to  this  disease,  or  the  disease  with  which  it  may  be  complicated. 
It  is  for  this  reason,  that  Portal  has  said,  that  in  making  these 
examinations,  it  is  highly  important  to  determine  between  the 
person  dying  with  a  jaundice,  and  the  person  dying  of  the  jaun- 
dice, that  we  do  not  incur  the  risk  of  false  induction.     Persons 
dying  of  jaundice,  have  almost  every  portion  of  the  body,  but 


ICTERUS,   OH   JAUNDICE.  567 

especially  the  cellular  and  adipose  membranes,  of  the  same  ge- 
neral tone  of  colour,  but  rather  less  deep  than  the  skin  presented 
before  death;  and  will  of  course  vary  in  intensity,  in  different 
individuals.  The  limbs  of  the  icteric  corpse  is  less  rigid,  or  ra- 
ther very  flexible  agreeably  to  Portal.  There  is  generally  a  ten- 
dency to  anasarca,  especially  in  the  face,  hands,  and  feet ;  at 
other  times  the  body  is  found  extremely  emaciated.  There  is  a 
yellow  serum  sure  to  follow  the  incision,  when  there  is  an  ana- 
sarcous  tendency  ;  the  same  colouring  may  be  found  in  all  the 
serous  cavities.  And  Portal  says  it  has  been  observed  sometimes 
in  the  aqueous  humour  of  the  eye. 

1899.  The  liver  is  more  frequently  found  changed,  than  any 
other  organ  of  the  body.    The  gall-bladder  is  variously  affected, 
both  in  its  structure,  and  in  the  quantity  and  appearance  of  its 
contents.  We  once  saw  it  thickened,  to  at  least  twenty  times  its 
ordinary  state ;  and  filled  with  very  many  calculi  of  different 
sizes;  sometimes  it  has  been  found  empty ;  at  others  enormously 
distended.    Van  Swieten  relates  a  case  in  which  there  was  more 
than  a  pound  of  bile  in  the  gall-bladder.     Sometimes  this  viscus 
has  been  found  inflamed,  thickened,  hardened,  or  covered  with 
fungous  elevations. 

1900.  The  ducts  of  the  liver,  both  the  cystic,  and  cholidic 
have  been  found  obliterated ;  or  obstructed  with  concretions  of 
various  sizes,  or  so  contracted,  as  to  refuse  the  entrance  of  the 
smallest  probe ;  and  Stoll  found  the  choledocus,  in  a  state  of  car- 
tilage ;  besides  very  many  other  pathological  conditions,  that 
would  be  both  tedious  and  useless  to  mention.   The  curious  may 
consult  upon  this  point  Morgagni,  or  the  more  recent  work  of 
Portal.     We  may  however  here  notice  two  curious  statements; 
first,  that  jaundice  has  been  absent,  in  cases,  where  the  ductu» 
choledocus  has  been  entirely  obliterated;  and  second,  that  jaun- 
dice has  been  present,  when  no  obstruction  had  been  offered  ta 
the  flow  of  the  bile — the  latter  we  have  endeavoured  to  account 
for  par.  1883,  but  the  former  if  true,  is  altogether  inexplicable  at 
present. 

Treatment. 

1901.  We  have  endeavoured  to  show,  that  the  causes  of  jaun- 
dice, are  both  numerous  and  obscure;  and  consequently,  the 
mode  of  treatment  must  always  be  uncertain,  if  not  very  often 
empirical ;  it  becomes  therefore  a  desideratum  of  moment,  to  as- 
certain the  determining  cause  of  the  disease.     It  is  not  difficult 
to  lay  down  a  plan  of  treatment,  (theoretically,)  for  each  particu- 
lar variety,  but  to  distinguish  that  variety  at  the  bedrside,  is  al- 
ways of  great  difficulty,  and  is  sometimes  altogether  impossible. 


568  ICTERUS,  OR    JAUNDICE. 

Who  will  pretend  to  distinguish  between  an  obstruction  of  the 
common  duct  caused  by  an  inflammation  of  this  canal,  and  such 
as  may  arise  from  spasm  ;  a  viscid  substance  secreted  within  it; 
a  mechanical  pressure  from  the  duodenum ;  or  a  too  inspissated 
condition  of  the  bile  itself?  yet  these  different  causes  operate  in 
their  turn,  and  require  a  difference  in  treatment.  The  first 
would  perhaps  only  yield  to  the  abstraction  of  blood ;  the  second 
would  call  for  ample  doses  of  opium,  which  would  be  destructive 
in  the  first.  The  third  would  not  be  benefited  by  either  of  these 
treatments,  and  the  fourth  might  require  a  long  application  of 
constitutional  remedies.  We  cannot  in  our  present  ignorance, 
lay  down  the  diagnostic  marks,  if  they  possess  any;  and  from 
this  inability  we  are  obliged,  to  treat  the  disease  more  or  less 
empirically. 

1902.  But  in  the  absence  of  the  signs,  that  might  lead  to  the 
belief  of  a  permanently  deranged  state  of  the  liver,  spleen,  pan- 
creas, or  other  viscera,  we  may  take  upon  trust,  the  other  causes 
enumerated,  (par.  1877,)  and  place  some  reliance  upon  the  state 
of  the  pulse,  and  general  condition  of  the  system,  as  guides  for 
general  remedies.     It  may  however  be  observed,  that  in  the  ab- 
sence of  all  inflammatory  action  in  any  portion  of  the  liver  or  its 
appendages,  the  action  of  the  heart  and  arteries,  in  jaundice,  is 
below  the  natural  standard  of  frequency,  and  consequently  free 
from  all  pyrexial  movement;  and  this  will  obtain  most  probably 
in  each  of  the  cases  supposed  above,  with  the  exception  of  the 
first — in  this  case,  we  believe  ourselves  warranted  in  saying,  the 
system  always  will  betray  a  phlogistic  movement. 

1903.  It  will  therefore  be  at  onee  admitted,  that  the  first  of 
the  enumerated  causes,  will  require  for  its  removal  a  different 
treatment  from  those  that  immediately  follow.     On  this  admis- 
sion, we  would  treat  every  case  of  jaundice  with  an  increased 
pulse,  by  blood-letting;  and  this  to  an  extent,  that  would  insure 
a  constitutional  change  of  arterial  action — that  is,  there  should 
be  a  tendency  to  syncope,  or  a  decided  sickness  of  stomach. 
This  must  be  followed  by  local  depletion  by  leeches  or  cups,  be- 
tween the  navel  and  the  lower  extremity  of  the  sternum.     The 
bowels  should  be  kept  open  by  castor  oil  and  injections;  and 
the  patient  made  to  drink  freely  of  gum  Arabic  water,  flaxseed, 

'  or  slippery-elm  bark  tea.  Care  should  be  taken  to  avoid  all 
stimulating  articles,  and  the  patient  be  confined  to  these  articles 
alone,  for  both  nourishment,  and  drinks.  The  oil  should  be  the 
only  purgative;  but  even  this,  must  not  be  unduly  urged. 

1904.  We  believe,  that  when  spasm  of  the  ductus  choledocus 
is  the  cause  of  the  disease,  it  will  like  that  caused  by  biliary 
calculi,  be  attended  with  pain,  and  this  oftentimes  of  a  very  se- 
vere character — in  both  these  cases,  opium  in  large  doses,  will 


ICTERUS,  OR   JAUNDICE.  569 

perhaps  be  the  only  effectual  remedy.  But  in  this  belief,  do  not 
let  it  be  forgotten,  that  the  pulse  must  be  carefully  consulted  be- 
fore we  administer  this  powerful  remedy — for  should  there  be 
an  increased  pulse  accompanying  either  of  these  cases,  bleeding 
to  an  effectual  amount  must  precede  the  use  of  the  opium.  This 
will  be  absolutely  necessary,  unless  the  pulse  be  slow  and  slug- 
gish ;  thus  manifesting  a  freedom  from  all  local  irritation.  In- 
deed, could  we  be  certain,  that  gall-stones  are  the  cause  of  the 
obstruction,  which  we  can  sometimes  be  assured  of  from  former 
illnesses  of  the  patient,  the  bleeding,  aided  by  a  long-continued 
use  of  a  moderately  warm  bath,  should  precede  every  other  at- 
tempt to  relieve  pain — it  will  dispose  to  the  necessary  relaxation 
of  the  biliary  ducts,  and  render  the  action  of  the  opium  more 
efficient,  as  well  as  less  hazardous.  On  this  account,  we  are  sur- 
prised at  the  expressions  of  authors,  who  attribute  as  a  cause  of 
jaundice  the  torpid  state  of  the  biliary  ducts,  when  connected 
with  gall-stones.  As  if  this  condition  of  these  tubes,  would  not 
be  the  .most  favourable,  for  the  transmission  of  these  bodies ; 
especially,  as  we  have  no  evidence  that  the  ducts  possess  a  pe- 
ristaltic motion,  from  the  liver  to  the  duodenum. 

1905.  Perhaps  this  plan  of  treatment  would  also  succeed, 
when  the  duct  was  obstructed  by  a  viscid  secretion  within  its 
tract;  as  we  know  that  depletion  by  blood-letting,  changes  the 
mode  of  action  of  every  secreting  surface.     Should  it  arise  from 
any  mechanical  pressure  exerted  by  the  contents  of  the  duode- 
num, and  which,  we  have  reason  to  believe,  is  a  more  frequent 
cause  than  is  generally  admitted,  a  brisk  cathartic  will  sometimes 
quickly  remove  the  disease.     We  have  seen  a  number  of  in-- 
stances  of  jaundice  speedily  relieved  by  two  or  three  active 
purges.     If  it  be  caused  by  an  inspissated  condition  of  the  bile, 
it  will  not  perhaps  be  removed  without  the  use  of  constitutional 
remedies;  and  mercury,  with  the  extract  of  taraxacum,  will  be 
the  most  effectual. 

1906.  We  have  seen  jaundice  removed  in  several  instances, 
by  the  liberal  use  of  the  supercarbonate  of  soda,  and  keeping  the 
bowels  loose  by  castor  oil.     How  the  soda  acted  to  produce  this 
end,  we  do  not  pretend  to  say — we  merely  record  the  fact. 
Emetics  are  highly  recommended  by  some — Darwin  extols  their 
efficacy,  especially  in  two  cases ;  these  were  cases  produced  by 
calculi;  in  such  instances  they  may  succeed  sometimes;  but  as 
a  general  remedy,  we  would  seriously  deprecate  their  employ- 
ment, unless  there  was  the  most  entire  evidence,  that  there  was 
no  febrile  movement  in  the  system  at  large,  or  inflammatory  irri- 
tation in  the  ducts  themselves.     Specifics  for  jaundice  have  had 
their  day ;  and  are  now  no  longer  employed  by  the  well-edu- 

73 


570  DIARRHOEA. 

cated  physician — it  is  needless  therefore  to  enumerate  the  many 
that  have  been  in  vogue. 

1907.  Of  the  mode  of  treatment  proper  in  jaundice  arising 
from  a  diseased  condition  of  the  liver  itself,  or  any  of  the  neigh- 
bouring, or  remote  viscera,  and  giving  rise  to  the  green,  or  black 
jaundice,  we  can  say  very  little,  to  encourage  perseverance,  or 
flatter  hypothesis.     The  cure  must  depend  upon  the  removal  of 
the  remote  cause,  and  not  upon  any  application  for  the  specific 
symptoms  of  jaundice — consequently,  the  cure  of  this  complaint 
is  altogether  dependent  upon  the  disease  that  gave  rise  to  it. 

SECT.  III. — DIARRHOEA. 

1908.  By  this  we  understand  a  too  frequent  discharge  of  the 
feculent  contents  of  the  bowels  without  tenesmus.     The  great 
variety  of  appearance  in  the  matters  discharged,  has  rendered 
it  proper  to  divide  this  disease  into  several  species;  and  first,  of 

1.    The  Feculent  Diarrhoea. 

1909.  Whatever  is  capable  of  increasing  the  peristaltic  mo- 
tion of  the  bowels,  or  even  perhaps  a  portion  of  them,  may  occa- 
sion the  disease  in  question;  hence  the  frequency  of  this  com- 
plaint. 

1910.  This  increased  action  of  the  bowels,  in  this  species  of 
diarrhoea,  may  be  occasioned  both  directly,  and  indirectly. 

a.  Directly. 

1911.  By  improper  or  irritating  substances  being  carried  into 
them  ;  as  food  of  a  bad  quality ;  or  too  much  of  that  which  may 
be  good,  when  taken  in  improper  proportions. 

1912.  The  stomach  not  being  able  to  digest  its  contents,  the 
bowels  become  stimulated  by  the  ill-subdued  food  urged  into 
them,  and  make  an  effort  to  dislodge  it  as  quickly  as  possible, 
by  increasing  their  peristaltic  motion;  hence,  their  contents  are 
rapidly  and  successively  transmitted  through  them,  and  occasion 
what  is  called  the  feculent  diarrhoea.     Or  it  may  be  occasioned 
by  the  presence  of  bile  in  the  duodenum;  this  bile  may  be  either 
in  too  great  quantity,  or  it  may  be  highly  depraved  in  its  qua- 
lity; and  may  in  either  condition  so  affect  the  peristaltic  mo- 
tion, as  to  produce  diarrhoea. 

1913.  This  is  the  most  simple  form  of  diarrhoea;  and  it  very 
often  effects  its  own  cure  by  the  profuseness  of  its  discharge : 
but  should  it  not,  a  dose  of  magnesia,  if  there  be  any  evidence 


DIARRHOEA.  571 

of  acidity,  or  castor  oil,  or  rhubarb,  if  there  be  none,  will  almost 
always  be  sufficient  for  this  purpose.  Should  it  not,  it  may  be 
repeated,  but  followed  by  an  appropriate  dose  of  laudanum  at 
bed-time,  should  the  fever  not  be  considerable.  ":'f '•' 

1914.  Should  there  be  much  nausea,  or  many  efforts  to  puke, 
it  will  always  be  best  to  cleanse  the  stomach,  as  these  symptoms 
are  almost  sure  to  arise  from  the  presence  of  a  portion  of  what- 
ever substance  may  have  been  offensive.     For  this  purpose,  we 
have  ever  found  calomel,  in  proper  doses,  the  best  possible  re- 
medy ;  for  it  is  almost  as  certain  to  cause  puking  under  such  cir- 
cumstances, as  a  medicine  decidedly  possessing  emetic  proper- 
ties, and  this  without  the  inconvenience  of  the  latter  remedy. 
The  dose  of  calomel  for  the  adult  may  be  eight  or  ten  grains. 

1915.  This  complaint  should  never  be  neglected;  especially  at 
such  seasons  of  the  year,  as  are  most  favourable  for  its  produc- 
tion ;  namely,  during  the  excessive  heat  of  summer,  or  when  the 
weather  becomes  cool  in  the  fall ;  for  when  not  attended  to,  it  is 
apt  to  degenerate  into  a  habit,  and  to  be  of  extremely  difficult  re- 
moval. 

b.  Indirectly. 
• 

1916.  Diarrhoea  may  be  induced  by  the  bowels  sympathizing 
with  some  other  part;  as  with  the  skin,  upon  a  sudden  check  of 
perspiration  ;  the  application  of  cold  to  the  surface  of  the  body; 
or  by  the  improper  use  of  the  cold  bath.     With  the  brain,  from 
agitation  of  mind,  particularly  that  of  anger  and  fear. 

1917.  When  diarrhoea  is  produced  by  indirect  agency,  espe- 
cially cold,  it  will  frequently  continue,  even  after  the  cause  which 
produced  it  is  removed.     This  kind  is  rarely  accompanied  by 
pain  unless  fever  be  excited;  in  which  case  the  bowels  suffer  some- 
times very  much  ;  the  skin  is  often  very  hot  and  dry ;  consider- 
able thirst,  and  white  tongue.     There  is  almost  always  mucus 
mixed  with  the  faeces  in  such  cases. 

1918.  This  case  is  treated  very  much  like  the  former,  except 
where  pain  and  fever  attend  ;  then  castor  oil  is  the  best  remedy. 
This  should  be  given  in  ounce  doses,  every  two  or  three  hours, 
until  it  operate  freely;  or  until  the  oil  is  observed  to  pass  through 
the  bowels  with  the  faeces.  If  considerable  pain  continue  after  the 
operation  of  the  oil,  the  warm  bath  may  be  used  most  advan- 
tageously.    If  perspiration  be  excited,  the  fever  will  quickly 
pass,  though  the  tormina  of  the  bowels  may  remain. 

1919.  Should  this  be  so,  an  injection  with  a  proper  quantity 
of  laudanum  may  be  given.     This  plan  of  purging,  bathing,  and 
giving  laudanum,  must  be  continued  as  the  symptoms  may  indi- 
cate, until  the  disease  ceases. 


572  DIARHHffiA. 

1920.  During  the  whole  management  of  diarrhoea  the  strictest 
regard  must  be  paid  to  the  diet,  and  drinks  of  the  patient    The 
former  should  consist  of  either  of  the  diluted  jellies  of  rice,  ta- 
pioca, sago,  or  arrow  root ;  the  latter  should  consist  of  thin  flax- 
seed  tea,  barley  water,  rice  water,  gum  Arabic  water,  or  an  infu- 
sion of  the  slippery-elm  bark. 

1921.  We  are  aware,  that  many  are  opposed  to  the  use  of  lau- 
danum in  the  early  stages  of  diarrhoea;  but  we  think  they  are  too 
indiscriminate  in  the  rejection  of  this  remedy.     We  are  our- 
selves adverse  to  its  administration,  where  the  bowels  have  not 
been  freely  opened  by  the  exhibited  medicine ;  where  there  is 
fever;  or  where  there  is  no  pain  ;  but  where  neither  the  want  of 
due  purging,  nor  fever  make  a  contraindication,  we  almost  always 
give  a  few  drops  at  night,  and  especially  if  the  patient  be  very 
restless,  or  in  pain.     We  are  persuaded  we  very  much  abridge 
this  complaint  by  this  plan;  and  most  certainly  prevent  its  run- 
ning into  a  chronic  form,  after  we  have  removed,  as  far  as  in  our 
power,  the  exciting  causes  of  the  disease. 

1922.  During  the  continuance  of  this  disease  we  strictly  for- 
bid animal  food,  or  animal  juices  under  any  form.     No  solid 
food  whatever  should  be  given  during  the  existence  of  this  com- 
plaint ;  and  every  kind  of  liquor,  whether  fermented  or  distil- 
led should  be  peremptorily  forbidden. 

2.  Of  the  Bilious  Diarrh&a. 

1923.  In  this  species  the  faeces  are  loose,  copious,  and  of  a 
bright  yellow,  or  green  ;  and  the  bowels  are  stimulated  to  inor- 
dinate action,  by  an  overcharge  of  bile  either  vitiated,  or  not. 
The  influence  of  a  hot  sun  upon  the  actions  of  the  liver,  is  well 
known  to  every  body;  and  it  is  familiar  to  common  observa- 
tion, that  after  a  spell  of  very  warm  weather,  even  the  healthy 
evacuations  give  evidence  of  its  rapid   formation,  and   some- 
times of  its  abundant  absorption.  -  Thus    the  fseces  are   ob- 
served to  be  loaded  with  bile,  and  the  urine  to  be  deeply  tinged 
with  it 

1924.  During  our  summers,  the  action  of  heat  is  both  uniform 
and  excessive ;  the  liver  feels  its  influence,  and  is  forced  to  an 
inordinate  secretion  of  bile,  which  being  suddenly  and  rapidly 
poured  into  the  bowels,  stimulates  them  to  an  excessive  action, 
either  by  quantity  or  quality,  or  both,  and  thus  the  "  bilious  di- 
arrhoea" is  produced. 

1925.  This  action  of  the  bowels,  as  in  the  species  just  consi- 
dered, sometimes  relieves  them  of  their  stimulating  contents, 
and  will  by  this  means  effect  their  own  cure — hence  this  species, 
like  the  other,  may  be  ephemeral ;  and  is  not  more  formidable 


DIARRHOEA.  573 

than  the  feculent  species,  unless  the  formation  of  bile  goes  on  al- 
most indefinitely ;  or  that  fever  is  provoked. 

1926.  The  plan  of  treating  this  form  of  diarrhoea  will  suggest 
itself;  the  bowels  must  be  evacuated  of  their  contents;  and  that 
by  the  remedy  which  so  decidedly  and  successfully  exerts  a  con- 
troul  over  the  actions  of  the  liver ;  namely,  calomel,  in  small,  but 
repeated  doses,  until,  from  the  change  in  the  appearance  of  the 
evacuations,  it  is  judged  the  purging  has  been  carried  sufficiently 
far ;  that  is,  when  a  little  of  the  mucus  of  the  bowels  appear  in 
the  stools. 

1927.  At  night,  in  the  absence  of  fever,  the  motion  of  the 
bowels  should  be  tranquillized  by  a  proper  dose  of  laudanum — 
preferably  by  injection  if  practicable;  if  not,  it  must  be  given 
by  the  mouth.     Should  the  complaint  reappear  the  next  day, 
the  calomel  may  be  repeated,  but  at  longer  intervals,  but  only 
in  sufficient  quantity  to  procure  a  decided  evacuation;  this  should 
again  be  followed  by  the  anodyne,  and  so  on  until  the  disease 
disappear.* 

1928.  The  diet  and  drinks  should  be  the  same  as  before  re- 
commended ;  except,  that  rennet  whey  answers  an  admirable 
purpose,  both  as  nourishment  and  drink,  in  this  species  of  diar- 
rhoea. 

1929.  If  fever  attend,  more  purging  will  be  required  than  if 
it  be  absent;  but  after  the  bowels  have  been  properly  evacuated 
by  the  calomel  in  the  beginning,  castor  oil,  or  rhubarb  and  mag- 
nesia, should  be  used. 

1930.  If  we  can  place  any  reliance  upon  the  accuracy  of  our 
own  observation,  we  can  with  much  safety  declare,  that  beef  tea 
or  any  other  diluted  animal  extract,  has  uniformly  been  attended 
with  bad  consequences,  in  the  commencement  of  almost  all  affec- 
tions of  the  bowels;  and  this  from  a  twofold  action.     1st,  it  is 
too  stimulating  when  applied  to  the  surface  of  the  irritated 
bowels;  and  2d,  in  affording  too  much  nourishment  for  the  fe- 
brile condition  of  the  system.  We  therefore  make  it  a  first,  and 
positive  direction,  that  no  animal  substance  of  any  kind,  or  in 
any  shape,  shall  be  given  in  diarrhoea,  even  in  its  most  simple 
form,  when  attended  with  bilious  discharges ;  and  we  positively 
prohibit  liquor  of  every  kind. 

1931.  But  we  nlust  not  be  understood  to  forbid  all  nutritious 

*  Dr.  Scudamore  relates  the  following  case  to  show  the  advantage  of  topical 
bleeding  in  obstinate  and  painful  diarrhoea. — Observations  on  Mr.  Laennec's 
Method,  We.  p.  59. 

"  A  gentleman  had  been  troubled  with  diarrhoea,  which  was  often  painful, 
for  two  or  three  months.  It  had  resisted  the  usual  treatment  by  medicine.  By 
one  application  of  leeches  near  the  rectum  he  was  cured." 


574  DIARRH03A. 

substances  to  the  patient;  this  we  do  not  do;  but  we  are  very 
particular,  both  as  regards  quantity  and  quality,  when  nourish- 
ment is  permitted. 

1932.  It  may  be  proper  to  observe,  that  in  the  species  of  diar- 
rhoea we  are  now  considering,  we  have  not  made  as  some  have, 
(Good,  &c.)  yellowness  of  the  evacuation  essential  to  it — we  very 
often  see  them  of  various  shades  of  green,  from  the  bright  grass- 
green,  to  the  bottle  or  black-green;  this  is  sometimes  accompa- 
nied by  a  frothy  top,  or  the  whole  mass  looking  spongy,  resem- 
bling very  much  the  green  production  on  the  top  of  stagnant 
water;  at  other  times,  it  is  of  pitchy  darkness,  and  tenacity. 
Where  the  last  is  observed,  it  has  always  been  preceded  by  a 
pretty  obstinate  fever,  which  does  not  usually  yield  until  these 
black  evacuations  come  away. 

1 933.  Much  injury  has  been  sustained  by  mistaking  green  bile 
for  acidity,  and  administering  the  cretaceous  mixtures,  so  as  to 
arrest  the  discharge  suddenly;  authors  abound  with  cases  of  cho- 
lera, convulsions,  fever,  &c.  arising  from  this  cause.   It  therefore 
becomes  very  important  that  the  one  should  not  be  mistaken  for 
the  other.     But  we  shall  have  occasion  to  revert  to  this  subject 
presently. 

3.    Of  Mucous  Diarrhoea. 

1934.  The  evacuations  consisting  of,  or  containing,  a  copious 
discharge  of  mucus.     This  species  is  commonly  produced  by  a 
sudden  check  of  perspiration,  or  the  sudden  application  of  cold 
to  the  surface  of  the  body  and  feet.     We  have  seen  it  follow  in 
two  instances,  in  children,  the  improper  use  of  the  cold  bath. 

1935.  Fever  rarely  accompanies  this  complaint,  in  its  milder 
forms;  and  it  is  of  easy  management  in  general;  but  sometimes 
we  have  known  it  very  obstinate.  The  remote  causes  should  not 
be  repeated,  if  possible  to  prevent  their  reapplication ;  if  it  pro- 
ceed from  cold  bathing,  it  must  be  discontinued  ;  and  if  from  at- 
mospheric cold  applied  to  the  body,  additional  clothing  must  be 
resorted  to,  &c. 

1936.  The  bowels  should  be  gently  purged  by  castor  oil,  and 
its  operation  followed  in  the  evening  by  a  suitable  dose  of  lauda- 
num.    This  plan  must  be  pursued  daily,  until  the  bowels  are 
relieved ;  or  they  may  be  opened  by  rhubarb  and  magnesia  dur- 
ing the  day,  and  followed  as  before  directed,  by  an  anodyne  in 
the  evening.     The  diet  should  consist  of  such  articles  as  have 
been  already  directed ;  and  the  patient  take  freely  of  an  infusion 
of  slippery-elm  bark,  or  gum  Arabic  water. 

1937.  Dr.  Good  condemns  the  use  of  purgatives  in  this  species 


DIARRHOEA.  575 

of  diarrhoea,  but  upon  no  good  ground,  that  we  can  perceive — 
our  experience  is  decidedly  in  favour  of  the  plan  just  proposed.* 
He  would  certainly  employ  laxatives  in  dysentery,  to  which  it 
bears  a  pretty  strong  analogy,  as  far  as  regards  effects  and  appear- 
ances ;  only  in  the  mucous  diarrhoea,  there  is  in  general  no  vas- 
cular excitement,  and  therefore  most  probably  no  very  active 
inflammation,  though  certainly  considerable  intestinal  irritation; 
whereas,  in  dysentery,  more  or  less  always  attends.  Dr.  Good 
certainly  would  evacuate  in  catarrh,  to  which  he  says  it  has  "a 
striking  resemblance." 

1938.  He  and  others  recommend  in  this  affection,  or  in  any 
"  other  looseness  produced  by  a  sudden  chill  upon  the  surface, 
small  doses  of  ipecacuanha,  with  or  without  opium."     We  have 
used  this  prescription  at  night,  and  we  think  with  evident  ad- 
vantage ;  but  it  should  not  be  given  in  the  day,  unless  there  is 
considerable  pain;  and  then  only,  after  an  evacuation  of  faeces 
has  been  procured.. 

4.   Chylous  Diarrhoea. 

1939.  This  form  consists  of  chylous  or  milky  evacuations.  It 
would  appear  that  there  is  a  deficiency  of  bile  in  this  disease,  as 
the  dejections  are  not  tinged  with  this  substance — consequently, 
this  complaint  would  seem  necessarily  to  be  accompanied  by 
some  derangement  of  the  hepatic  system,  either  positively  or  ac- 
cidentally.    The  liver  may  not  be  in  a  condition  to  secrete  this 
fluid  abundantly,  or  its  flow  into  the  intestines  is  by  some  means 
or  other  impeded. 

1940.  In  treating  this  complaint,  whether  it  be  pretty  sudden- 
ly induced,  or  it  follow  a  diarrhoea,  we  have  always  prescribed 
for  the  condition  of  the  stomach,  and  we  may  safely  say,  we 
have  generally  succeeded.     We  should  withhold  almost  all  food 
from  the  stomach,  that  its  weakened  powers  need  not  be  longer 
overtaxed.    We  therefore  confine  the  patient  to  small  quantities 
at  a  time  of  rennet  whey  or  gum  Arabic  water — nothing  else  is 
permitted.     We  endeavour  to  restrain  the  passages,  by  an  ano- 
dyne injection,  of  full  power,  at  night;  and  give  during  the  day 
minute  doses  of  calomel — say  a  grain  every  four  hours,  with  the 
fourth  or  sixth  of  a  grain  of  opium.    We  persevere  in  this  treat- 
ment for  a  few  days,  unless  the  calomel  urge  the  bowels  too 
much ;  in  this  case,  we  diminish  the  quantity  of  calomel,  and  in- 
crease that  of  the  opium. 

*  It  will  be  perceived,  that  by  purgatives,  we  only  mean,  the  most  lenient  of 
the  class.  We  would  deprecate  the  use  of  the  more  active  substances  of  this 
class  of  medicine,  as  earnestly  as  Dr.  Good;  but  we  cannot  at  present  reject 
the  use  of  castor  oil,  or  rhubarb  and  magnesia  occasionally. 


576  DIARRHffiA. 

1941.  We  have  seen  the  most  decided  relief  from  this  plan; 
and  by  giving  the  stomach  very  little  to  do,  it  becomes  recon- 
ciled to  its  duties,  and  fulfils  them  after  a  little  while  perfectly. 

5.  Lienteric  Diarrhcea. 

1942.  "The  rapid  passage  of  the  nearly  unchanged  aliment 
through  the  bowels,  constitutes  this  species  of  diarrhoea."  With 
children,  it  sometimes  follows  the  other  species  of  diarrhoea,  and 
dysentery  perhaps  oftener.  It  is  not  accompanied  by  much  acute 
pain,  though  the  child  appears  uneasy  after  eating;  but  is  imme- 
diately relieved  by  an  evacuation,  which  is  perceived  to  consist 
of  the  food  a  little  while  previously  taken  into  the  stomach.  This 
complaint  rarely  comes  on  suddenly,  and  it  may  exist  in  different 
degrees.     When  a  tendency  to  this  complaint  is  first  perceived, 
it  should  be  instantly  attended  to,  for  it  is  one  of  those  affections 
that  rarely  if  ever  cures  itself. 

1943.  It  generally  commences  during  the  chronic  state  of  di- 
arrhoea, by  showing  perhaps,  that  some  one  article  of  diet  only 
has  passed  the  bowels  unchanged. 

1944.  This  complaint  seems  to  be  seated  altogether  in  the  sto- 
mach itself,  and  owes  its  existence  to  the  great  irritability  of  this 
organ  ;  for  so  soon  as  the  food  is  lodged  in  it,  it  makes  efforts,  by 
an  increased  peristaltic  action,  to  discharge  it,  and  the  intestines 
transmit  it  with  equal  speed  to  their  extremity,  there  to  be  dis- 
charged.    Dr.  Good  suggests  that  "the  gastric  juice  may  not  be 
secreted  in  proper  quantity,  or  with  proper  qualities ;"  this  may 
be,  but  it  is  not  sufficient  to  account  for  the  phenomena;  for  this 
happens  precisely  in  dyspepsia,  but  dyspepsia  is  not  constantly 
attended  with  lientery. 

1945.  We  have  been  in  the  habit  of  treating  this  disease  very 
much  after  the  manner  of  "chylous  diarrhoea,"  to  which  it  has 
a  very  strong  resemblance,  in  the  rapidity  with  which  the  food 
is  passed  through  the  tract  of  the  intestinal  canal ;  and  it  would 
seem  to  be  but  an  excess  of  it — in  the  one,  the  stomach  digests 
to  a  certain  extent,  but  confessedly  imperfectly,  as  the  ill-con- 
cocted mass  is  hurried  from  the  stomach  into  the  intestines  be- 
fore it  can  be  properly  elaborated.    In  the  disease  in  question,  it 
tarries  a  still  snorter  time,  and  for  the  most  part  passes  with  little 
or  no  change. 

1946.  We  have  found  this  disease,  generally  speaking,  to  be 
a  manageable  one,  when  sufficiently  early  attended  to ;  but  when 
suffered  to  run  on  to  the  last  stage  of  debility,  little  or  nothing 
can  be  done ;  it  but  too  generally  proves  fatal,  as  it  for  the  most 
part  takes  place  in  feeble  and  worn  out  constitutions,  that  have 


DIARRHOEA.  577 

been  exposed  to  the  effects  of  hot  climates,  or  after  chronic  dy- 
sentery or  diarrhoea. 

6.   Of  the  Chronic  Form  of  Diarrhoea. 

1947.  The  several  species  of  diarrhoea  already  treated  of,  may 
run  into  a  chronic  form  of  very  difficult  management,  as  well  as 
of  great  danger;  1st,  by  neglect;  2d,  by  the  continuance  of  the 
remote  and  exciting  causes ;  or  3d,  by  improper  treatment. 

Of  the  Treatment  of  Chronic  Diarrhoea. 

1948.  Everybody  has  experienced  the  difficulty  of  removing 
a  diarrhoea,  after  it  has  taken  on  a  chronic  form.     This  arises 
from  several  causes:  1st,  because  the  hepatic  system  is  now  in- 
volved with  the  intestinal,  in  maintaining  this  complaint;  2d, 
because  the  stomach  and  bowels,  independent  of  the  condition 
of  the  liver,  are  seriously  affected  by  either  inflammation,  ulce- 
ration,  contractions,  or  intro-susceptions ;  3d,  because  the  influ- 
ence of  habit  to  too  frequent  dejections,  is  added  to  the  original 
disposition. 

1949.  When  the  first  cause  of  difficulty  prevails  alone,  the 
disease  for  the  most  part  is  of  pretty  easy  management ;  the 
symptoms,  here,  may  consist  of  too  frequent  discharges,  of  a 
green,  slimy,  or  curdled  appearance;  with  loss  of  appetite,  nau- 
sea, sometimes  vomiting,  and  of  increasing  emaciation;  the  skin 
almost  always  dry,  and  very  warm  where  covered ;  the  urine 
scanty  and  high-coloured ;  the  thirst  great ;  and  the  disposition 
fretful,  whimsical,  or  sluggish.     Three  indications  here  present 
themselves:  1st,  to  alter  the  nature  of  the  actions  of  the  stomach, 
bowels,  and  liver;  2d,  to  abate  the  frequency  of  the  discharges; 
and  3d,  to  restore  the  lost  strength  of  the  parts  immediately  con- 
cerned, and  the  system  in  general. 

1950.  The  first  indication  must  be  fulfilled  by  freely  empty- 
ing the  bowels  by  castor  oil,  rhubarb,  or  calomel ;  and  then  by 
giving  small  doses  of  calomel,  that  is,  from  a  half  to  a  grain, 
morning  and  evening,  with  three  or  four  grains  of  prepared 
chalk,  and  from  a  fourth  to  an  half  a  grain  of  ipecacuanha,  and 
as  much  opium.     The  second  must  be  attempted  either  by  small 
doses,  say  four  or  five  grains,  three  times  a  day,  of  rhubarb,  or 
by  the  cretaceous  mixture.    At  night  a  sufficient  quantity  of  lau- 
danum by  the  mouth,  or  by  injection,  should  be  given,  to  keep 
the  bowels  quiet  until  the  morning. 

1951.  Nothing  heating  or  stimulating  should  be  given  either 
as  nourishment,  or  as  drink;  and  every  species  of  liquor,  animaJ 
food,  or  broth,  must  be  prohibited.     The  diet  must  consist  only 
of  such  articles  as  the  stomach  can  best  manage,  as  milk  ajid 

73 


578  DIARRHffiA. 

water,  gum  Arabic  and  water,  very  thin  arrow  root,  sago,  or 
tapioca ;  rennet  whey,  barley  water,  or  rice  water.  Nothing  solid 
of  any  kind  should  be  given.  The  occasional  use  of  melted  but- 
ter is  found  sometimes  highly  advantageous  in  every  state  almost 
of  chronic  diarrhoea.  It  is  made  by  pouring  boiling  water  on  a 
lump  of  perfectly  sweet  butter  in  a  tea-cup,  and  stirring  it  until  it 
is  melted  ;  a  tea-spoonful  is  skimmed  from  the  top,  and  given  se- 
veral times  a  day.  This  prescription  is  however  for  children  alone. 

1952.  The  third  indication  may  be  fulfilled  by  the  proper 
use  of  diet — permitting  the  use  of  weak  broths,  without  vegeta- 
bles being  boiled  in  them,  with  the  exception  of  rice;  but  even 
this  must  be  strained  from  them  before  they  are  given.     A  soft- 
boiled  fresh  egg  may  after  a  while  be  given;  or  a  little  well-boiled 
rice,  with  sugar,  very  fresh  butter,  and  a  little  nutmeg,  may  be 
made  to  follow  from  time  to  time. 

1953.  Where  there  is  chronic  inflammation,  the  disease  must 
be  considered  not  only  very  far  advanced,  but  highly  dangerous. 
Here  we  shall  find  the  pulse  is  very  much  accelerated  ;  pain  will 
be  experienced  by  pressure  upon  the  abdomen;  the  skin  will  be 
hot  and  parched  ;  the  evacuations  extremely  frequent  and  offen- 
sive; a  disposition  to  tenesmus;  or  the  evacuations  may  be  spar- 
ing, slimy,  very  watery,  or  bloody,  though  frequent;  the  thirst 
be  excessive;  and  the  tongue  dry,  red,  and  furred.     All  these 
symptoms,  or  the  greater  part  of  them,  will  attend  chronic  in- 
flammation of  the  mucous  tissue  of  the  intestines. 

1954.  The  indications  here,  are,  1st,  to  abate  the  local  in- 
flammation ;  2d,  to  change  the  nature  of  the  secretions  of  the 
liver  and  bowels,  and  to  allay  the  irritation  of  the  intestines;  3d, 
to  diminish  the  frequency  of  the  discharges;  and  4th,  to  restore 
lost  strength. 

1955.  The  first  indication  must  be  attempted  to  be  fulfilled  by 
local  depletion  by  leeches ;  by  the  occasional  use  of  the  warm 
bath ;  by  blisters  on  the  abdomen  or  thighs.     The  second,  by 
the  exhibition  of  the  calomel  in  alterative  doses ;  and  by  small, 
but  repeated  doses  of  castor  oil.     The  third,  by  the  occasional 
use  of  laudanum  enemata,  when  they  can  be  retained ;  or  by  its 
exhibition  in  small,  but  frequent  doses,  by  the  mouth.    And  the 
fourth,  by  proper  diet,  as  above  proposed  ;  by  exercise;  and  by 
change  of  air,  or  climate. 

1956.  In  this  and  in  the  subsequent  stage,  it  may  be  proper 
to  observe,  that  nothing  but  rennet  whey  or  weak  gum  Arabic 
water,  should  be  given  as  nourishment,  and  even  these  in  very 
small  quantities.*     Thirst  is  best  slaked  by  toast  water,  given 
from  time  to  time. 

•  We  are  persuaded,  that  one  of  the  most  operative  causes  against  recovery, 
in  every  bowel  complaint,  is  the  too  frequent  exhibition  of  food,  both  proper 
and  improper^  especially  during  its  active  stage.  The  fear  of  weakness  leads 


DYSENTERY.  579 

1957.  When  this  disease  is  still  more  advanced,  and  has  been 
•of  long  continuance,  we  have  a  right  to  suspect,  what  has  been 
but  too  often  proved  by  dissection  to  happen  under  such  circum- 
stances,  contractions,  ulcerations,  and    intro-susceptions.     We 
have  no  diagnostic  symptoms  for  these  conditions  of  the  bowels; 
and  if  we  had,  it  might  be  justly  doubted  whether  the  knowledge 
of  them  would  lead  to  any  valuable  practical  end.     We  fear  that 
in  these  cases,  no  other  plan  can  be  pursued,  but  a  temporising 
one ;  for  it  is  to  be  presumed,  that'  every  effort  has  been  made 
during  the  previous  stages  of  the  disease  to  arrest  its  progress. 

1958.  Habit  sometimes  perpetuates  the  discharges  from  the 
bowels ;  this  cause  may  be  suspected  when  the  evacuations  occur 
at  nearly  stated  periods  of  the  day;  when  they  are  not  continued 
through  the  night,  and  when  the  digestion  goes  on  well,  and  the 
stools  look  natural.    Children  from  the  long  continuance  of  diar- 
rhoea, and  those  of  sufficient  age  to  feel  a  sense  of  shame,  and 
especially  those  who  have  been  schooled  into  good  habits  in  re- 
gard to  their  evacuations,  are  always  sure  to  obey  the  first  im- 
pulse or  warning  the  bowels  give  that  a  discharge  is  about  to 
take  place,  and  by  this  means  no  doubt  have  provoked  an  eva- 
cuation, which  a  little  self-command  might  have  checked.     By 
this  means  almost  all  influence  over  the  sphincter  is  lost,  and  the 
discharge  is  maintained  from  habit. 

1959.  Laudanum  we  have  found  the  best  remedy  for  this  kind 
of  diarrhoea,  especially  when  combined  with  prepared  chalk ;  it 
should  be  given  as  frequently  as  the  state  of  the  bowels  would 
seem  to  require — that  is,  given  immediately  after  each  evacuation, 
and  directing  the  patient  not  to  obey  the  desire  as  long  as  they 
can  possibly  resist  it. 

SECT.  IV. — DYSENTERY. 
Character  and  Symptoms. 

1960.  We  understand  by  dysentery,  an  inflammatory  affec- 
tion of  the  mucous  membrane  of  the  large  intestines ;  this  is 
attended  by  a  frequent  and  irresistible  desire  to  go  to  stool,  ac- 
companied by  violent  inclination  to  discharge  the  contents  of  the 
rectum,  without  a  corresponding  ability ;  the  effort  for  the  most 

incessantly  to  error,  on  this  subject;  and  neither  reason  nor  experience  is  capa- 
ble of  destroying  this  absurd  and  dangerous  practice.  Every  body  would  at 
once  acknowledge  it  to  be,  not  only  preposterous,  but  even  cruel,  to  place  an 
additional  weight  upon  the  shoulders  of  a  man  who  was  staggering  under  the 
load  already  laid  upon  them;  but  they  would  think  it  right  to  do  what  is  equally 
absurd  and  cruel  to  the  stomach,  by  forcing  upon  it  a  fresh  quantity  of  food, 
when  it  has  not  power  to  dispose  of  that  which  it  had  previously  received. 


580  DYSENTERY. 

part,  ending  principally,  in  the  expulsion  of  mucus.  This  mucus 
may  be  tinged  sparcely ;  or  the  discharge  may  be  nearly  or  alto- 
gether blood — when  the  tinge  is  sparce,  it  is  generally  produced 
by  a  few  drops  of  blood  more  or  less  pure — if  the  whole  evacu- 
ation be  stained,  it  is  by  the  colouring  matter  of  the  blood  dif- 
fusing itself  pretty  generally  through  the  mass.  When  this  hap- 
pens, the  discharge  loses  the  appearance  of  pure  mucus,  and 
strictly  resembles,  what  it  is  commonly  compared  to,  the  colour- 
ed "  scrapings  of  guts."  Sometimes  there  will  be  a  small  quan- 
tity of  faeces  of  a  green  and  curdled  appearance  accompanying 
the  discharge  ;  at  other  times,  a  very  small  quantity  of  mucus, 
and  a  considerable  proportion  of  pure  blood. 

1961.  These  discharges  are  always  preceded  by  severe  tor- 
mina or  cutting  pains,  attended,  and  followed  by  tenesmus,  to  a 
greater  or  less  extenU— as  a  general  rule,  the  greater  the  tenes- 
mus,  the  more  frequent  the  desire,  and  the  ability  less,  to  effect 
a  discharge.  In  this  case  the  evacuation  is  very  small  in  quan- 
tity, and  consists  chiefly  of  mucus,  or  only  of  a  little  pure  blood. 
The  efforts  are  at  times  so  extremely  powerful  and  repeated,  as 
to  exhaust  the  patient  very  much ;  his  face  will  often  be  covered 
with  sweat,  or  he  may  even  faint.  When  the  tenesmus  is  very 
violent,  it  seems  to  destroy  the  power  of  the  bladder  to  discharge 
its  urine,  a  retention  therefore  occasionally  takes  place,  which 
very  much  augments  the  sufferings  of  the  patient.  The  lower 
part  of  the  abdomen  is  generally  hard,  rather  tumid,  and  always 
more  or  less  tender  to  the  touch.  The  stomach  is  sometimes 
nauseated;  at  other  times,  vomiting  attends;  the  back  for  the 
most  part  is  extremely  painful;  the  patient  however,  most  com- 
monly lies  upon  it,  with  his  feet  drawn  up.  The  skin  is  com- 
monly hot  and  dry;  at  other  times  preternaturally  cold,  especially 
the  extremities;  the  tongue  is  generally  covered  with  a  white 
fur,  while  its  margin  and  tip,  are  oftentimes  red.  The  pulse, 
accelerated,  contracted,  and  tense;  and  always  manifesting  more 
or  less  fever;  though  it  is  declared  by  some,  that  dysentery  is 
sometimes  unattended  by  fever* — but  we  have  never  seen  this  in 
genuine  dysentery,  though  we  have  frequently  witnessed  only  a 

•  Sydenham  describes  dysentery  as  ordinarily  unattended  by  fever?  he 
says,  "In  the  year  1662,  cholera,  dry  gripes,  or  colic  without  stools  and  dy- 
sentery, were  very  frequent.  In  the  following  autumn  the  last  two  diseases 
returned;  and  in  the  midst  of  their  raging  appeared  a  new  kind  of  fever,  which 
accompanied  both  diseases."  He  called  this  usual  symptom  of  dysentery,  the 
"fcbris  dysenterica."  Cullen  on  the  other  hand,  regards  fever  as  a  leading 
symptom  of  dysentery.  We  think  it  however  every  way  agreeable  to  obser- 
vation, that  fever  is  generally  in  proportion  to  the  disturbance  or  perhaps,  ra- 
ther to  the  degree  of  inequality,  of  sanguine  distribution,  and  the  degree  of 
nervous  susceptibility. 


DYSENTERY.  581 

very  slight  degree  of  it ;  thirst  always;  and  sometimes  insatiable. 
The  stools  have  a  peculiar  odour. 

Diagnosis. 

1962.  This  disease  cannot  well  be  mistaken  for  any  other; 
its  characters  are  too  strongly  and  peculiarly  marked,  to  need 
our  dwelling  upon  its  diagnosis,  though  Fournier  and  Vaidy  have 
run  a  long  parallel  between  it,  diarrhrea,  cholera  morbus,  and 
haemorrhoids.  But  the  severe  suffering;  the  frequent  and  urgent 
calls  to  the  pan;  the  mucous,  bloody,  sparing  discharges;  their 
peculiar  odour,  together  with  fever,  will  readily  distinguish  this 
affection  of  the  bowels  from  every  other,  without  our  descending 
to  further  details. 

Nosological  Position  and  Pathology. 

1963.  Dysentery  has  been  placed  properly  by  Pinel,  among 
the  inflammations  of  the  mucous  membranes — for  multiplied  dis- 
sections prove,  that  this  complaint  owes  its  origin  to  an  inflam- 
mation of  this  membrane  of  the  large  intestines,  and  it  has  rarely 
been  found  to  transcend  their  limits.*     Observation  also  proves, 
in  the  great  majority  of  cases,  that  this  inflammation  is  confined 
to  this  tunic ;  and,  that  neither  the  muscular,  nor  peritoneal  coats 
are  involved  in  the  mischief. 

1964.  It  has  been  almost  uniformly  supposed,  that  the  bowels 
were  ulcerated  in  dysentery,  especially,  when  accompanied  by 
bloody  discharges;!  all  the  older  writers,  from  Hippocrates  down- 
ward, have  declared  this  condition  essential  to  it.     It  was  not 
until  Morgagni's  splendid  work  was  before  the  public,  that  the 
faith  in  this  opinion  was  shaken,  as  he  cites  many  authorities, 
who  declare  they  have  frequently  seen  ulcerations  in  the  bloody 
flux.     But  Morgagni  mentions  but  a  single  case  of  this  kind ; 
we  have  therefore  every  right  to  conclude,  he  did  not  meet  with 
them,  or  he  would  have  mentioned  it.   Broussais  makes  no  men- 
tion of  ulceration,  except  when  this  disease  is   chronic ;    and 
Fournier  and  Vaidy,  declare,  that  in  twenty  years  experience 

*  In  certain  cases  of  dysentery,  "black  vomit"  has  attended;  tny  friend  Dr. 
Physick  and  myself  saw  two  instances  of  this  kind  in  two  children,  one  five, 
the  other  seven  years  old — one  died  on  the  fifth  and  the  other  on  the  sixth 
day  of  the  disease.  In  these  instances,  an  inflamed  stomach,  similar  to  that  pro- 
ducing yellow  fever,  complicated  these  cases. 

f  "In  dysentery  the  blood,  however  copious  it  may  appear,  oozes  from  a 
large  extent  of  surface  of  the  lower  end  of  the  ileum,.and  from  that  of  the  co- 
lon, without  ulceration  or  gangrene,  and  evidently  from  the  vessels  of  the  vil- 
lous  membrane,  which  during  health  secrete  mucous  and  intestinal  fluid."—- 
Craige'i  General  and  Pathological  Anat.  p.  208. 


582  DYSENTERY. 

and  research  in  a  public  hospital,  where  they  witnessed  dysentery 
in  all  its  forms,  that  they  found  ulceration  to  be  extremely 
rare  ;  and  never  scarcely,  but  where  this  disease  had  assumed  a 
chronic  form.  Bayle  and  Cayol,  also  say,  that  ulceration  is  not 
the  ordinary  result  in  dysentery,  properly  so  called. 

1965.  Dissections  show  that  the  mucous  membrane  of  the 
large  intestines,  and  sometimes,  though  rarely,  a  part  of  the  small, 
are  found  red,  or  brown,  rough,  and  somewhat  thickened  in  their 
whole  extent.     This  rough  surface  is  besmeared  with  a  glairy, 
or  purulent  matter,  or  a  bloody  sanies.     This  appearance  has 
led  some,  not  well  skilled  in  post  mortem  examinations,  into  a 
belief  that  the  whole  of  the  mucous  membrane  was  deeply  ul- 
cerated.    But  if  the  process  recommended  by  M.  Cayol  be  fol- 
lowed, this  error  will  be  quickly  corrected.     He  directs,  that 
this  matter  should  be  gently  scraped  by  the  back  of  a  scalpel, 
and  the  intestine  washed  in  plenty  of  water ;  we  will  then  see 
that  the  substance  which  was  taken  for  ulcerations,  will  detach 
itself  and  disappear.     It  is  however  acknowledged  by  some,  that 
ulceration  may  occasionally  be  discovered ;  but  as  they  do  not 
appear  to  be  in  proportion  to  the  violence,  or  extent  of  the  pre- 
vious inflammation  ;  and  as  others  have  never  met  with  these  ul- 
cerations, even  ia  persons  who  have  died  of  violent  bloody  dy- 
sentery, it  is  fair  to  conclude,  that  ulcerations  are  not  the  essen- 
tial cause  of  this  disease. 

1966.  There  appears  to  be  something  peculiar  in  the  oeconomy 
of  the  intestinal  mucous  membrane,  while  labouring  under  cer- 
tain conditions,  or  under  certain  states  of  inflammation.     For  in 
chronic  diarrhoea,  which  we  cannot  but  think  is  maintained  by 
a  sub-acute  form  of  inflammation,  ulcerations  are  frequently  met 
with;  especially  in  portions  of  the  coecum,  rectum,  and  in  the 
sigmoid  flexion  of  the  colon;  sometimes,  though  rarely,  in  the 
last  convolution  of  a  small  intestine,  but  never  in  the  duodenum. 
From  this  it  would  appear,  that  the  intensity  of  the  inflammation 
does  not  direct  the  formation  of  ulcers,  since  it  must  be  acknow- 
ledged to  be  much  more  intense  in  dysentery,  yet  where  they 
are  rarely  found,  than  in  the  chronic  inflammation  of  a  long- 
standing diarrhoea — they  are  particularly  common  in  the  diar- 
rhoea which  attends  the  last  stage  of  phthisis  pulmonalis,  agree- 
ably to  Bayle  and  Broussais. 

Causes. 

1967.  Dysentery  may  be  sporadic,  endemic,  or  epidemic,  as 
is  proved  by  many  authorities;  and  it  assumes  some  difference 
in  type  if  we  credit  these  authorities,  as  it  may  appear  in  the 


DYSENTERY.  583 

one  or  other  of  these  forms.  It  is  more  common  at  the  last  of 
summer  or  in  autumn  than  at  other  portions  of  the  year.  It  at- 
tacks all  ages  and  sexes ;  being  however  more  fatal  to  females 
and  children  than  to  males. 

1968.  This  disease  may  be  caused  by  a  sudden  suppression  of 
perspiration,  as  passing  suddenly  from  a  warm  atmosphere  while 
in  a  state  of  perspiration  into  a  cold  one.     Hot  and  humid  at- 
mospheres also  act  as  remote  or  predisposing  causes.     High  or 
mountainous,  as  well  as  very  low  situations,  are  liable  to  dysen- 
tery ;  and  certain  soils  appear  to  dispose  to  the  endemic  form  of 
this  disease,  as  it  constantly  happened,  that  this  disease  first  ap- 
peared in  the  lime-stone  part  of  the  soil  in  Abingdon  township, 
Montgomery  county,  during  the  five  years  residence  of  the  au- 
thor in  that  neighbourhood.     He  also  has  had  occasion  to  ob- 
serve the  same  prevalence  of  dysentery  in  parts  of  Centre  county 
of  this  state,  (Pennsylvania.) 

1969.  The  neglect  of  cleanliness  has  been  a  fruitful  source  of<* 
dysentery,  especially  in  the  army.     Fournier  says,  they  "  re- 
ceived into  the  hospitals,  soldiers  encrusted  with  excrement  and 
dust."     Unwholesome  food  has  also  been  assigned  as  a  cause 
of  this  disease.     In  epidemic  dysentery,  a  peculiar  disposition 
of  the  air  is  the  reputed  cause ;  but  this  can  be  aided  by  un- 
wholesome aliment,  drinks,  and  habitations,  as  with  troops  in. 
camps,  &c. 

Is  it  Contagious?* 

1970.  This  disease  has  been  looked  upon  by  many  as  conta- 
gious ;  we  have  been  very  attentive  to  this  question  ever  since 
our  commencement  in  business;  and  our  opportunities  have  been 
ample,  as  well  as  frequent.  But  in  no  one  instance  have  we  had 
reason  to  believe  it  to  possess  this  quality  ;  an  epidemic  disease, 
we  are  certain,  has  been  mistaken  for  a  contagious  disease,  in 
many  of  the  reputed  instances  of  contagion  of  this  complaint, 
having  appeared  throughout  a  community. 

*  Dr.  Cullen  says,  that  dysentery  is  always  contagious;  in  this  he  is  followed 
by  many  writers,  as  well  as  its  being  a  popular  belief;  Pringle,  Hunter,  Harty, 
&c.  declare  the  same  thing.  To  this  opinion  Dr.  Johnson  well  remarks,  that, 
"either  the  dysentery  of  their  day  was  a  different  disease  from  what  it  is  now, 
or  these  eminent  individuals  were  betrayed,  by  their  preconceived  ideas,  into 
a  mistake.  It  is  surely  of  very  little  present  importance  which  of  the  alterna- 
tives may  be  the  truth;  for  opinions  must  now-a-days  be  decided,  not  by  autho- 
rity, but  by  the  touchstone  of  facts  carefully  observed,  and  carefully  record- 
ed."— Tropical  Climates,  p.  228. 


584  DYSENTERY. 


Terminations. 

1971.  Dysentery  may  terminate  in  health,  in  another  disease, 
or  in  death;  our  prognostic  must  be  founded,  therefore,  upon  its 
approach  to  one  of  them. 

1972.  When  our  remedies  have  been  successful,  we  find  an 
abatement  in  the  severity  of  the  symptoms  which  mark  this  dis- 
ease.    Fever  abates;  pain  diminishes;  the  calls  to  the  chair  be- 
come less  frequent;  tenesmus  is  appeased;  the  evacuations  as- 
sume a  natural  complexion ;  the  bloody  and  mucous  discharges 
disappear;  the  strength  renovates,  and  convalescence  ensues. 

1973.  This  happy  termination,  however,  is  not  always  perma- 
nent; errors  in  diet,  or  improper  exposure,  will,  and  too  often 
do  produce,  a  return  of  this  formidable  complaint;  and  this  at  a 
time,  when  the  powers  of  the  system  are  still  far  from  being  re- 
stored— when  this  happens,  the  patient  quickly  pays  the  forfeit 
of  his  life,  or  a  conversion  into  another  disease  takes  place,  which 
leaves  him  a  poor  choice  of  evils ;  either  a  more  or  less  speedy 
death,  or  an  endless  disease.     It  therefore  behooves  the  patient 
to  pay  the  strictest  regard  to  regimen,  clothing,  and  exercise. 
The  first  should  be  mild,  and  chiefly  consist  of  vegetable  sub- 
stances, as  rice,  in  its  various  forms,  tapioca,  arrow  root,  &c. ; 
and  this  should  be  continued  for  some  time,  or  until  pain  has  en- 
tirely ceased ;  the  evacuations  discharged  without  blood  or  mu- 
cus; without  tenesmus,  and  of  proper  consistence.  The  strength 
should  above  all  be  consulted;  for  if  this  do  not  accumulate  in  a 
proper  ratio  to  the  quantity  of  food  taken,  and  the  apparent  free- 
dom from  disease,  all  is  not  right — there  is  some  lurking  mis- 
chief, which  should  as  early  as  possible  be  detected. 

1974.  For  this  purpose,  the  evacuations  should  be  examined, 
the  urine  inspected,  and  the  pulse,  especially  towards  evening, 
be  carefully  consulted;  and  if  the  first  be  not  healthy  in  their 
character,  the  second  too  abundant  and  pale,  or  too  sparing  and 
high-coloured,  and  the  third  irritated,  we  may  be  certain,  that 
convalescence  is  not  about  to  be  firmly  established.  The  patient 
should  be  again  put  upon  the  moderate  use  of  the  vegetable  jel- 
lies of  rice,  tapioca,  the  demulcent  drinks,  &c.  and  the  bowels 
should  be  freely  opened  by  castor  oil,  or  rhubarb.  This  diet 
should  be  persevered  in,  and  the  bowels  kept  free,  until  a  change 
of  the  circumstances  for  which  they  were  ordered,  takes  place. 
And  if  these  unpleasant  conditions  be  removed,  the  patient  may 
again  gradually  resume  a  more  generous  diet — a  little  chicken- 
water,  or  beef-tea,  the  soft  end  of  a  few  oysters,  or  a  soft-boiled 
egg,  may  be  added  to  the  other  diet.  His  drink  should  still  be 
the  same  as  before ;  that  is,  as  during  his  disease ;  or  he  may  take 
toast-water,  or  some  mild  syrup  and  water ;  but  no  liquor  of  any 
kind. 


DYSENTERY.  585 


Conversion  into  othtr  Diseases. 

1 975.  Should  a  favourable  termination  of  dysentery  be  realized 
only  in  part,  the  acute  may  be  changed  into  the  chronic  form, 
diarrhoea,  dropsy,  &c. 

Chronic  Form. 

1976.  Chronic  dysentery  may  arise  from  the  recuperative 
powers  of  the  system  being  unequal  to  the  complete  restoration 
of  the  parts  that  were  involved  in  the  acute  stage  of  the  disease; 
this  may  happen  from  a  feeble  condition  of  the  bowels,  or  from 
the  disease  having  been  extreme  in  severity.     The  constitution 
may  have  sufficient  power  to  prevent  immediate  death,  though 
it  may  be  insufficient  for  the  establishment  of  health.  Or  it  may 
take  place  from  errors  in  diet,  suppression  of  perspiration,  the 
improper  use  of  stimulants,  &c. 

1977.  This  form  is  rarely  attended  by  manifest  fever,  though 
we  believe  the  pulse  is  always  more  or  less  irritated;  the  patient 
continues  without  an  increase  of  strength;  the  appetite  is  weak 
and  oftentimes  whimsical ;  spasms  of  greater  or  less  frequency 
are  still  felt  in  the  bowels ;  frequent  dejections,  and  more  or  less 
tenesmus.     The  patient  is  very  susceptible  to  cold;  is  listless, 
and  desirous  to  maintain  a  horizontal  position ;  and  when  he  lies, 
he  folds  himself  up  into  as  small  a  compass  as  possible.     Four- 
nier  says,  that  patients  of  this  kind,  "hide  their  heads  beneath 
the  bed-clothes ;"  he  says  this  is  characteristic,  and  that  every 
physician  of  experience  will  recognise  at  first  sight  a  patient  of 
this  kind,  by  the  squat  position  he  assumes  in  his  bed — we  have 
never  observed  this. 

1978.  The  countenance  is  sad,  pale,  or  yellow;  and  the  whole 
of  the  forearms  and  hands  become  covered  with  an  earthy-look- 
ing crust ;  this  never  fails  to  be  a  bad  sign.     The  skin  is  dry, 
and  rough  to  the  touch ;  the  lips  and  gums  are  without  colour ; 
the  face  becomes  oedematous  sometimes ;  the  patient  continually 
wastes;  the  dysenteric  odour  is  even  stronger  than  in  the  acute; 
indeed,  it  becomes  almost  insupportable..    The  pulse  is  feeble, 
slow,  intermittent,  with  evening  exacerbations  sometimes;  the 
belly  is  hard,  but  not  painful ;  the  urine  is  brown,  scalding,  and 
passes  off  with  difficulty ;  the  feet  and  legs  swell,  and  eventually 
become  hydropic. 

1979.  Fournier  observes  that  the  chronic  dysenteric  patients, 
are  in  several  respects  like  the  phthisical ;  namely,  that  "  they 
preserve  their  senses,  and  yield  themselves  to  the  formation  of 

74 


586  DYSENTERY. 

projects,  that  would  require  a  long  life  to  fulfil ;  also  like  the 
consumptive,  they  have  an  inordinate  desire  for  opium  ;  and  of 
which  they  will  support  enormous  doses."  Eventually,  lientery 
takes  place,  and  carries  off  the  patient. 

Pathology  of  Chronic  Dysentery. 

1980.  Dissection  shows  that  in  these  cases  it  is  the  mucous 
membrane  of  the  intestines  that  chiefly  suffers ;  it  becomes  thick- 
ened, rough,  covered  with  pustules,  and  ulcerated. 

1981.  We  may  remark  here,  that  this  process  does  not  appear 
to  depend  upon  the  extent  or  severity  of  the  acute  stage  of  the 
disease;  for  this  frequently  passes,  without  this  consequence; 
and  this  where  every  symptom  gave  evidence  of  the  grave  nature 
of  the  disease.      It  seems  rather  to  betray,  that  for  ulceration  to 
take  place,  requires  some  peculiar  condition  of  the  part  involved 
in  the  previous  active  inflammation,  rather  than  in  its  severity 
or  the  extent  of  irritation ;  and  hence,  in  examinations  after  death 
from  dysentery,  ulceration  of  the  mucous  membrane  of  the  in- 
testine is  frequently  absent. 

Complications. 

1982.  In  dysentery  death  may  ensue  simply  from  the  effects 
of  the  particular  fever  with  which  it  may  be  complicated.     For 
in  some  parts  of  the  world  it  may  be  joined,  agreeably  to  many 
authorities,  to  "adynamic,  ataxic,  or  typhus  fevers."     In  this 
country,  these  complications  are  rare ;  indeed  we  have  never 
seen  such  a  combination;  that  is,  as  either  of  these  fevers  joined 
to  dysentery,  and  having  an  origin  independent  of  the  condition 
of  the  mucous  membrane  of  the  intestines  itself.  The  dysentery 
in  many  instances  doubtless,  has  in  its  course  assumed  apparent- 
ly these  conditions,  like  all  other  diseases  of  the  febrile  kind  of 
high  action,  when  the  first  stage  has  been  neglected,  improperly 
treated,  or  when  its  force  was  beyond  the  protecting  powers  of 
the  system  to  resist  it  with  success.     Yet,  notwithstanding  this, 
we  must  insist  that,  in  this  portion  of  our  country  it  has  been 
uniformly  inflammatory,  as  far  as  our  observations  have  extend- 
ed. The  danger  therefore  of  dysentery,  will,  casteris  paribus,  be 
in  proportion  as  the  fever  accompanying  it  shall  depart  from  a 
pure  inflammatory  fever.     But  to  return: — 

1983.  When  dysentery  terminates  in  death,  it  is  as  we  have 
already  observed,  sometimes  by  gangrene  of  the  intestine.  When 
this  is  about  to  happen,  several  changes  take  place  in  the  gene- 
ral symptoms — pain  ceases  suddenly ;  the  pulse  becomes  slow, 


DYSENTERY.  587 

small,  and  unequal;  delirium,  if  it  had  existed,  ceases,  and  the 
patient,  as  in  yellow  fever,  thinks  himself  well,  and  nearly  the 
same  symptoms  take  place  as  in  enteritis,  which  see,  par.  2028. 
Termination  by  gangrene  however,  is  far  from  being  as  frequent 
as  has  been  declared  by  some  writers,  especially  Starck,  who 
says  all  that  die  of  this  disease,  die  from  gangrene.  Now,  mo- 
dern pathologists  do  not  confirm  this  assertion;  for  many,  as 
Broussais,  Cayol,  Bayle,  Fournier,  Vaidy,  &c.  deny  it.  When 
gangrene  does  take  place,  death  is  generally  produced  more 
rapidly,  than  when  this  happens  from  febrile  irritation. 

Prognosis. 

1984.  Dysentery  may  always  be  considered  as  a  disease  of 
severity ;  and  as  one  dangerous  in  proportion  to  the  intensity  of 
the  febrile,  and  other  symptoms.     Fournier  says,  that  this  dis- 
ease is  sometimes  without  fever — this  he  calls  "  simple  dysen- 
tery," and  considers  it  free  from  danger.     We  cannot  pretend 
to  judge  how  far  this  may  be  true ;  as  we  have  never  seen  a 
dysentery,  as  we  said  before,  unattended  by  fever,  though  we 
have  known  this  to  be  slight.     In  our  estimation  then,  it  may 
be  looked  upon  as  one,  if  not  at  the  moment  absolutely  danger- 
ous, yet  as  constantly  liable  to  become  so,  as  there  is  no  secu- 
rity against  an  aggravation  of  symptoms,  and  this  sometimes  from 
apparently  small  causes.     Errors  in  diet;  improper  treatment; 
imprudent  exposure,  or  an  unusual  susceptibility  of  the  system, 
may  at  any  moment  cause  an  alarming  increase  of  disease. 

1985.  When  dysentery  is  epidemic,  the  danger  may  be  in- 
creased by  the  character  of  the  fever  with  which  it  may  be  ac- 
companied ;  for  in  proportion  as  this  fever  may  be  dangerous  in 
itself,  will  be  that  of  dysentery. 

1986.  Evacuations  accompanied  by  purulent  discharges,  is 
always  a  bad  sign,  as  it  announces  the  suppuration  of  the  mucous 
membrane.     Or  if  the  evacuations  be  very  frequent,  very  offen- 
sive and  cadaverous;  very  thin  and  black;  or  if  they  be  dis- 
charged involuntarily,  or  living  worms  make  their  escape  in 
the  bed,  the  prognosis  is  very  bad.  Hiccough  is  also  a  bad  sign; 
and  if  the  mouth  be  covered  with  aphthae,  it  is  sure  almost  to  be 
fatal. 

1987.  If  after  severe  suffering  from  pains  in  the  abdomen,  and 
these  attended  by  violent  fever,  they  should  cease  suddenly,  we 
have  reason  to  fear  that  gangrene  has  taken  place.     Or  if  the 
evacuations  have  the  appearance  of  bloody  water,  or  like  the 
greasy  water  in  which  meat  has  been  boiled,  and  extremely 
fetid,  the  danger  is  extreme.     If  there  be  excessive  thirst,  it  is 
also  bad. 


588  DYSENTERY. 

1988.  Hiccough  in  an  advanced  stage  of  the  disease  is  always 
unfavourable,  though  not  so  in  the  commencement  of  it.  But  the 
discharge  of  a  hard  or  concrete  mucus,  so  resembling  membrane, 
as  to  give  rise  to  a  belief  that  the  internal  coat  of  the  intestine 
has  been  thrown  off,  is  not  always  a  fatal  symptom.     The  same 
may  be  said  of  the  little  wasses,  supposed  to  be  bits  of  flesh,  that 
are  occasionally  rendered  in  dysentery.    Fournier  says  they  are 
nothing  but  consolidated  blood,  portions  of  which  have  been  re- 
tained in  the  intestine.     He  also  says,  that  pimples  around  the 
nose  and  eyes,  indicate  a  long,  and  dangerous  disease. 

1989.  On  the  other  hand,  if  the  faecal  evacuations  become  con- 
sistent, the  disease  may  be  considered  as  having  very  much  di- 
minished, and  that  an  approach  is  making  towards  convalescence. 
If  fever  abate ;  if  thirst  slacken ;  if  pain  gradually  subside ;  if 
tenesmus  moderates ;  if  the  evacuations  become  less  frequent, 
with  an  increase  of  genuine  faeces ;  if  the  skin  relax,  and  be  dis- 
posed to  moisture ;  if  the  patient  lay  straighter  in  bed ;  if  the 
urine  be  sufficiently  abundant,  and  deposits  a  sediment,  and  the 
tongue  begins  to  clean,  we  may  generally  pronounce  a  consider- 
able amendment.   It  may  be  well  to  remark",  that  the  appearance 
of  pure  blood,  even  in  considerable  quantity,  is  not  to  be  looked 
upon  as  unfavourable— indeed,  we  have  thought  in   several  in- 
stances where  it  was  pretty  abundant,  that  it  afforded  much  re- 
lief, as  it  seemed  to  act  like  a  leeching  to  the  inflamed  intestine. 

1990.  If  to  these  be  added  tranquil  sleep,  an  increase  of  mus- 
cular strength,  and  a  return  of  a  natural  and  moderate  appetite, 
we  may  with  considerable  safety  pronounce  the  patient  out  of 
danger. 

Treatment. 

1991.  We  have  said,  that  we  had  seen  much  of  dysentery,  and 
that  it  had  constantly  in  this  portion  of  our  country,  presented 
the  character  of  an  inflammatory  disease;  and  that  this  obtained 
in  the  beginning,  in  all  instances  within  our  recollection,  to  a 
greater  or  less  degree.  This  character  continues  to  present  itself 
at  this  moment,  (1830,)  in  the  several  instances  we  have  now 
under  care  ;  nor  have  we  heard  of  any  contrary  statement,  from 
any  of  our  friends — we  have  declared,  that  post  mortem  exami- 
nations make  the  proximate  cause  of  dysentery  to  consist  of  an 
inflammation  of  the  mucous  membrane  of  the  large  intestines ; 
and  consequently,  that  its  treatment  will  consist  in  a  strict  anti- 
phlogistic plan. 

1992.  Bleeding  is  almost  constantly  necessary  in  dysentery; 
and  if  there  are  cases  in  which  it  is  not  required,  or  that  it  is  im- 
proper, they  offer  but  exceptions  to  the  rule,  either  from  the 


DYSENTERY.  589 

V  T 

mildness  of  the  character,  or  the  peculiarity  of  the  type  of 
fever,  which  accompanies  this  disease.  As  regards  the  first  ex- 
ception, we  have  certainly  met  with  cases  in  which  the  circum- 
stance mentioned  existed,  and  we  did  not  bleed — but  in  such  in- 
stances, the  pain  and  tenesmus  were  inconsiderable;  moreotless 
faeces  constantly  presented  themselves  in  the  evacuations;  the 
fever  was  very  slight,  and  the  bowels  easily  evacuated  by  very 
mild  cathartics,  or  gentle  laxatives.  In  such  cases,  it  is  generally 
sufficient,  that  a  dose  of  castor  oil  be  given  during  the  day,  and 
a  moderate  quantity  of  laudanum  at  night,  aided  by  a  properly 
regulated  regimen.  And  as  regards  the  second,  or  peculiarity 
of  type  of  the  fever,  if  it  be  such  as  will  not  bear  the  lancet,  it 
certainly  should  not  be  had  recourse  to.  But  do  not  let  us  be 
deceived  upon  this  point,  by  mistaking  the  character  of  the 
pulse;  a  risk  every  way  likely  to  be  run,  as  perhaps  there  are 
no  other  affections  of  the  system,  besides  those  of  the  alimentary 
canal,  in  which  the  pulse  is  so  uncertain  a  guide,  to  the  inexpe- 
rienced. For  if  the  bounding,  full  pulse,  that  attends  pneumonic 
and  some  other  affections  be  taken  as  the  guide  for  bleeding  in 
dysentery,  we  should  rarely,  or  never  bleed  in  this  disease; 
for  such  a  state  of  the  arterial  system  is  seldom  or  never  found 
to  attend  the  affections  of  either  the  intestines,  stomach,  or  ab- 
domen. 

1993.  Pain,  tenesmus,  mucous  discharges,  their  urgency  or 
frequency;  heat  of  skin,  acceleration  of  pulse,  and  thirst,  or  much 
blood,*  are  to  be  our  therapeutical  guides.     If  much  pain  attend, 
it  can  only  arise  from  the  intensity  of  inflammation;  nor  can  the 
other  enumerated  symptoms  have  any  other  cause ;  but  above 
all,  the  entire  constipation,  that  almost  always  takes  place  when 
this  disease  exists  in  any  force,  calls  imperiously  for  the  abstrac- 
tion of  blood ;  nor  is  there  any  other  single  means,  capable  of 
affording  the  necessary  relief.     We  therefore  without  hesitation 
have  recourse  to  it,  whenever  it  is  thus  called  for;  nor  are  we 
very  sparing  as  regards  quantity  in  some  instances ;  being  cer- 
tain, that  any  quantity  this  side  of  positive  effects,  will  be  of  lit- 
tle service. 

1994.  By  positive  effects  we  would  wish  to  be  understood,  an 

*  "When  blood  appears  alarmingly  in  the  stools,  whether  the  fever  run  high 
or  not,  venesection  may  be  employed  without  the  smallest  apprehension  of  that 
bugbear — DEBIMTT."— ^Johnson  on  the  Influence  of  Tropical  Climates  upon  Euro- 
pean Constitutions,  4th  ed.  p.  218. 

The  condition  pointed  out,  for  which  bleeding  is  so  confidently  and  properly, 
as  we  believe  prescribed,  is  of  very  rare  occurrence  in  our  climate — so  rare  in- 
deed is  it,  that  we  do  not  remember  ever  to  have  seen  an  excessive  discharge  of 
blood  attend  dysentery — but  if  it  occur,  we  are  of  opinion  that  topical  bleeding 
would  be  the  best  remedy — in  such  cases,  we  would  leech  from  the  anus. 


590  DYSENTERY. 

abatement  of  pain,  a  diminution  of  the  heat  of  skin,  a  reduction 
of  the  pulse,  paleness,  and  even  nausea,*  when  the  symptoms  are 
urgent.  We  repeat  the  bleeding,  and  have  recourse  to  leeching, 
as  directed  for  enteritis,  or  peritonitis.  In  a  word,  the  general 
treatment  is  so  precisely  similar,  that  it  is  unnecessary  to  detail 
it  here. 

1995.  In  dysentery,  however,  the  employment  of  laxative 
medicines  is  more  imperiously  called  for  than  in  enteritis;  espe- 
cially where  the  constipation  is  complete — that  is,  where   no 
fasces  show  themselves.     The  ol.  ricini,  or  castor  oil,  is  almost 
the  only  laxative,  when  the  stomach  will  bear  it,  that  can  be  ad- 
vantageously employed.     This  should  be  given  in  small  and  re- 
peated doses,  until  faeces  appear  in  the  evacuations — and  this 
should  be  made  to  take  place,  if  practicable,  three  or  four  times 
in  the  twenty-four  hours. 

1996.  The  active  cathartics  should  never  be  employed;  for 
ample  experience  in  the  commencement  of  our  treatment  of  dy- 
sentery, has  satisfactorily  proved  their  inexpediency — for  the 
constipation  is  never  removed  by  them,  but  at  the  expense  of  the 
revolt  of  the  stomach,  and  an  increase  of  pain,  and  an  aggrava- 
tion-of  every  other  symptom.!    Many  of  the  French  practition- 
ers proscribe  even  laxatives  in  this  disease,  as  they  do  in  ente- 
ritis— but  we  do  not  hesitate  to  use  them ;  and  for  the  same  rea- 
sons as  is  given  for  employing  them,  in  that  disease. 

1997.  It  sometimes  happens  that  the  castor  oil  cannot  be  taken, 
or  it  will  not  be  retained  ;  J  when  this  obtains,  we  generally  sub- 

*  "  Dr.  Mortimer,  in  a  report,  draws  the  attention  of  the  profession  to  the 
employment  of  ipecacuanha  in  dysentery,  given  in  nauseating  doses  immedi- 
ately after  bleeding1,  either  general  or  topical,  followed  by  a  dose  of  castor  oil. 
This  remedy  was  exhibited  to  the  extent  of  five  grains,  (mixed  with  some 
powdered  gum  Arabic,)  every  hour  or  second  hour,  as  the  patient's  stomach 
would  bear  it  without  actual  vomiting.  During  the  taking  of  this  medicine,  no 
fluids  were  permitted  to  be  swallowed.  The  nausea  is  rather  distressing,  and 
vomiting  is  often  induced,  but  not  desired.  Sweat  is  generally  induced.  The 
improvement  of  the  biliary  secretion  under  the  administration  of  the  ipecacu- 
anha was  manifest." — Johnson's  Med.  Chirur.  Rev.  for  Oct.  1832,  p.  409. 

f  A  most  common,  and  mischievous  error  prevails  in  the  treatment  of  dysen- 
tery, (arising  from  a  theory  of  this  disease,)  namely,  purging  freely  by  the  more 
active  cathartics,  until  scybalae  are  removed.  Cullen  was  an  advocate  for  this 
active  purging.  The  notion  of  these  hard  substances  being  the  cause  of  dysen- 
tery, gave  rise  in  part  to  this  practice;  but  unfortunately  for  the  hypothesis, 
these  balls  are  rarely  met  with,  and  appear  to  be  rather  the  consequences  of 
returning  power  in  the  intestines,  than  the  cause  of  the  disease. 

$  Sometimes  the  oleaginous  mixture  will  sit  upon  the  stomach,  when  the 
plain  oil  will  be  rejected.  This  is  made  by  triturating  an  ounce  of  the  oil  with 
a  quantity  of  powdered  gum  Arabic  and  loaf  sugar — adding  gradually  six 
ounces  of  water — a  table-spoonful  of  this  may  be  given  every  hour  until  it  pro- 
cure fecal  discharges. 


DYSENTERY.  591 

Fp"-       -••    '  'v-'V  •'•  ""»  *    ' 

stitute  the  sulphate  of  magnesia  and  the  tartrite  of  antimony, 
when  no  nausea  attends,  with  much  advantage.* 

1998.  Should  pain,  tenesmus,  and  fever  continue,  bleeding  or 
leeching  should  be  again  resorted  to ;  bleeding,  if  with  these 
symptoms  the  heat  of  skin  be  considerable,  and  the  pulse  still 
active ;  leeching,  if  these  two  last  do  not  obtain.     Tenesmus  is 
one  of  the  most  troublesome  symptoms  that  attends  this  disease; 
in  some  instances  an  almost  constant  nisus  is  kept  up,  by  the 
rectum  urging  the  patient  to  frequent,  but  unavailing  efforts  to 
discharge  the  contents  of  the  bowels;  producing  at  the  same 
time,  a  sensation  as  if  the  whole  of  the  intestines  were  escaping. 
These  efforts  are  so  often  repeated,  that  the  patient  becomes  ex- 
hausted by  their  importunity  and  pertinacity ;  sometimes  oblig- 
ing him  to  rise  from  twenty  to  eighty  times  in  the  twenty-four 
hours.  Zimmerman  says  he  has  seen  patients  go  two  hundred  times 
in  the  same  period.    Much  injury  is  sometimes  sustained  by  the 
patient,  by  constantly  obeying  the  desire  to  go  to  the  commode — 
this  should  be  resisted  as  much  as  possible ;  and  if  the  patient  be 
firm  in  his  purpose,  he  will  find  he  can  resist  for  a  long  time 
these  importunities  of  the  rectum.     This  fact  we  have  well  as- 
certained in  our  own  experience ;  and  the  attempt  to  restrain 
these  inordinate  demands  to  go  to  the  pan  will  often  succeed. 
This  was  well  known  to  the  ancients,  and  it  is  especially  recom- 
mended by  Celsus,  lib.  iv.  xvi.     "  Et  cum  in  omori  fluore  ven- 
tris,  turn,  in  hoc  precepue  necessarium  est,  non  quoties  libet 
desidere,  sed  quoties  necesse  est ;  ut  hcec  ipsa  mora  in  consue- 
tudinem  ferendi  oneris  intestina  deducat."     Leeching  the  anus 
is  highly  useful  in  this  case. 

1999.  It  is  every  way  important,  that  this  irritation  should  be 
allayed  as  quickly  as  possible ;  and  for  this  purpose,  besides  the 
remedies  just  proposed,  we  must  have  recourse  to  opium,  in 
some  shape  or  other.  Laudanum,  or  a  watery  solution  of  opium, 
given  in  the  form  of  enemata,  is  generally  the  best.    The  lauda- 
num answers  very  well  in  common ;  but  we  have  known  the 
rectum  so  much  inflamed,  and  so  completely  deprived  of  its  na- 
tural and  protecting  mucus,  as  to  be  unable  to  bear  the  stimulus 
of  the  alcohol  contained  in  it.     In  tnis  case  the  watery  solution 
answers  extremely  well.     From  three  to  six  grains  of  opium,  as 
the  patient  may  require,  must  be  dissolved,  or  well  rubbed  with 


*  R.  Sulph.  magnesia   -        -    §j. 
Tartrite  antim.       -        -    gr.  j. 
Manna  opt.  -        -     5j. 

Succ.  lemon.         -        -    5ss. 
Aq.  fervent.  -        -    }|v5ij. 

f.  sol.  et  colat. 


Take  Epsom  salts         «'•       1  ounce. 
Tartar  emetic      -         1  grain. 
Flake  manna       -        1  ounce. 
Lemon  juice        -        i  ounce. 
Hot  water   -        -        8  ounces. 
Make  a  solution,  and  strain. 


A  table-spoonful  every  hour  or  two,  until  it  procure  stools. 


592  DYSENTERY. 

two  or  three  table-spoonfuls  of  hot  water,  and  then  strained 
through  a  cloth;  to  this,  an  equal  quantity  of  rich  mucilage  of 
gum  Arabic,  flaxseed  tea,  arrow  root,  or  starch,  must  be  added, 
and  given  at  bed-time  as  an  enema.  Should  laudanum  be  found 
to  answer,  a  tea-spoonful  may  be  administered  in  the  same  way. 
Should  it  be  returned  quickly,  and  without  abating  the  irritation, 
it  may  be  repeated  in  half  an  hour  or  an  hour.  Mercury  to  sali- 
vation is  highly  recommended  by  Dr.  Johnson.  It  may  be  given 
both  by  the  mouth,  and  by  the  skin.  After  due  depletion  in 
tropical  climates  especially,  he  gives  scruple  doses  of  calomel 
two  or  three  times  a  day  until  it  produce  ptyalism.  In  using 
calomel,  he  insists  on  the  quantity  named — as  either  a  lesser  or 
greater  quantity,  offends  the  stomach  and  irritates  the  bowels. 

2000.  Sometimes,  the  enemata  are  rejected  almost  as  fast  as 
given,  without  affording  the  slightest  relief;  when  this  happens, 
we  have  found,  that  by  giving  the  laudanum  with  a  solution  of 
the  acetate  of  lead,  that  they  would  be  retained  better.    The  so- 
lution may  be  made  by  dissolving  ten  grains  of  the  acetate,  in  a 
common-sized  wine-glassful  of  water ;  to  this  the  laudanum  must 
be  added,  and  given  as  an  enema.     We  have  occasionally  found 
a  small  suppository,  of  six  or  eight  grains  of  the  solid  opium,  to 
answer  extremely  well. 

2001.  It  must  however  be  borne  in  mind,  that  opium  is  not  to 
be  used  in  any  form,  until  the  pulse  be  sufficiently  reduced  to 
bear  it — that  is,  the  same  rule  must  be  observed,  as  in  any  other 
inflammatory  febrile  affection.     The  plan,  then,  of  treatment, 
consists  in  the  due  abstraction  of  blood,  so  long  as  pain  continues, 
and  the  pulse  will  bear  it;  in  gently  moving  the  bowels  by  laxa- 
tives, and  relieving  pain  by  opium.     Advantage  is  sometimes 
found  in  warm  applications  to  the  bowels — as  flannels  wrung  out 
of  warm  water,  brandy,  or  whiskey.    We  have  occasionally  wit- 
nessed relief,  from  having  the  abdomen  bathed  with  the  spirit  of 
turpentine. 

2002.  We  cannot  guard  with  too  much  care,  the  diet  and 
drinks  of  the  patient;  they  should  be  the  same  as  in  enteritis; 
for  there  is  no  disease  in  which  errors  of  diet  incur  a  severer 
penalty ;  nor  none,  in  which  so  much  mischievous  vulgar  error 
prevails;  in  proof  of  this,  we  need  only  mention  the  almost  uni- 
versal administration  of  "mutton  broth;"  this  pernicious  sub- 
stance is  in  almost  universal  use  among  those  who  attempt  to 
treat  the  disease  themselves;  and  it  is  too  frequently  admitted  as 
an  article  of  diet,  by  some  medical  men. 

2003.  Blisters  to  the  abdomen  have  been  highly  recommend- 
ed by  some — our  own  experience  is  against  their  application  to 
this  part — we  have  found  advantage  from  their  application  to  the 


DYSENTERY.  593 

inside  of  the  thighs,  when  tenesmus  has  been  very  severe ;  and 
after  the  proper  reduction  of  the  pulse. 

2004.  After  faecal  stools  are  procured  with  facility,  the  danger 
for  the  most  part  is  over,  or  certainly  very  much  diminished ; 
but  when  these  cannot  be  provoked,  the  danger  augments,  and 
gangrene,  with  all  its  horrors,  is  certainly  impending — but  be- 
ware how  you  stimulate — for  in  no  case  is  it  more  true,  that  we 
must  not  stimulate,  because  we  cannot  deplete,  than  in  dysentery. 
In  this  condition  of  things,  we  must  mainly  rely  upon  the  resto- 
rative powers  of  the  system ;  avoiding  at  the  same  time  most 
carefully,  every  thing  like  active  treatment,  as  it  would  certainly 
interfere  with  this  power. 

2005.  The  chronic  form  of  this  disease  permits  but  little  be- 
yond a  pro  re  nata  treatment — keeping  the  bowels  free  by  mild 
laxatives,  and  a  mild  vegetable,  or  mucilaginous  diet ;  the  shun- 
ning of  all  stimulating  drinks  or  medicines ;  and  the  occasional 
and  judicious  use  of  opium,  will  perhaps  comprise  every  thing 
advantageous  in  our  power.  If  fever  of  any  particular  type  com- 
plicate dysentery,  it  must  be  treated  agreeably  to  its  character — 
at  least  as  far  as  the  state  of  the  bowels  will  permit  the  appro- 
priate treatment. 

Convalescence. 

2006.  A  patient  escaping  from  dysentery,  cannot  be  too  care- 
ful about  his  clothing;  this  should  consist  of  materials  rather 
warmer  than  is  necessary  for  health ;  but  above  all,  he  should 
not  fail  to  wear  flannel  next  his  skin.    It  is  idle  for  him  to  rebel 
against  this  direction,  by  saying  he  "  never  wore  flannel  in  his 
life" — there  never  was  before  a  necessity  perhaps  for  it ;  or  if 
there  had  been,  and  he  neglected  it,  he  should  not  compound  for 
one  error,  by  pleading  the  commission  of  another.     He  should 
be  particularly  careful  in  his  diet ;  he  should  neither  eat  to  satiety 
of  even  proper  food,  nor  take  such  as  is  improper  in  itself;  as 
stimulating  animal  substances,  or  broths,  or  liquor  of  any  kind. 
For  it  is  easy  to  overtax  the  stomach,  and  supply  more  material 
to  the  sanguiferous  system,  than  the  exigencies  of  the  system  re- 
quire.    He  should  be  careful  not  to  overheat  himself,  or  have 
perspiration  suddenly  checked;  he  should  avoid  all  damp  places, 
and  never  permit  his  feet  to  remain  cold — a  change  of  air  may 
be  highly  important,  especially  if  he  cannot  enjoy  proper,  and 
well-directed  exercise  at  home. 

2007.  Exercise  must  be  looked  upon  like  any  other  remedy — 
it  may  be  improper  in  quality,  and  excessive  in  quantity.     It 
should  be  performed  in  the  open  air,  in  dry  and  properly  select- 
ed weather ;  and  its  degree  should  never  exceed  the  quantity  of 

75 


594  ENTERITIS. 

strength  the  patient  may  have  to  spare — for  if  it  do,  it  then 
amounts  to  fatigue,  and  fatigue  is  injurious. 

SECT.  V. — ENTERITIS.* 

2008.  By  enteritis  we  are  to  understand  an  inflammation  of 
the  internal  coat  of  the  intestines.     We  have  emphasized  the 
"internal  coat  of  the  intestines,"  as  Good  and  Gregory,  two  of 
the  latest  British  writers  on  practical  medicine,  seem  to  have 
confounded  peritonitis  with  enteritis;  a  mistake  of  great  patholo- 
gical and  therapeutical  consequence.  The  first  seems  to  be  at  no 
pains  to  ascertain,  whether  the  inflammation,  which  he  admits 
to  be  present,  is  situated  in  the  serous  or  mucous  coat  of  the  in- 
testines.t   It  is  true  he  makes  two  varieties;  one,  "adhesive  in- 
flammation of  the  bowels ;"  and  the  other,  "  erythematic  inflam- 
mation of  the  bowels ;"  but  locates  neither,  with  any  certainty. 
In  describing  these  species,  he  says  of  the  first,  "  pain  very  acute, 
fever  violent;  vomiting  frequent,  and  costiveness  obstinate;"  of 
the  second,  "  pain  more  moderate,  fever  less  violent,  little  vomit- 
ing, and  diarrhosa  instead  of  costiveness."     In  neither  of  these 
characters,  nor  in  his  specific  definition  of  enteritis,  does  he  point 
out  the  seat  of  the  disease,  nor  indicate  the  tissue  involved  in  the 
inflammation.  Indeed,  this  appears  to  be  a  matter  of  indifference; 
since  he  founds  no  therapeutical  views  upon  his  varieties,  though 
he  insinuates,  that  his  first,  may  be  seated  in  the  mucous  mem- 
brane, by  saying,  that  "it  has  been  well  ascertained,  that  the 
seat  of  the  erythematic  is  sometimes  in  the  external  coat  of  the 
intestines ;  and  it  is  said  by  some  writers,  that  this  is  the  most 
common  seat."J 

2009.  From  this  it  would  appear,  that  Dr.  Good  had  either 
not  made  up  his  mind  upon  the  seats  of  the  varieties  of  enteritis, 
or  that  he  thought  it  a  matter  of  no  consequence  to  do  so.     At 
this  we  are  not  a  little  surprised ;  a  man  of  his  great  erudition 
and  research,  could  not  have  been  ignorant  of  the  important  dis- 
tinctions made  by  Bichat  of  the  inflammations  of  the  several 
tissues  composing  the  body,  or  have  been  indifferent  to  them, 
after  having  made  himself  master  of  them;  especially,  as  he  is 

•  We  have  said  nothing  of  gastritis,  thinking  the  observations  on  yellow  fe- 
ver, (which  is  only  a  high  grade  of  this  affection,  and  usually  in  an  epidemic 
form,)  would  be  every  way  sufficient,  and  to  which  we  beg  leave  to  refer. 

•}•  Dr.  Armstrong  says,  "inflammation  of  the  serous  membrane  of  the  sto- 
mach only  occurs  now  and  then,  and  is  mostly  conjoined  with  mucous  inflam- 
mation of  that  viscus;  whereas  inflammation  of  the  serous  membrane  of  the 
bowels  is  very  frequent  in  this  country,  (England,)  and  is  in  the  majority  of 
cases,  unconnected  with  the  inflammation  of  the  mucous  texture." — Morbid 
Anatomy  of  the  Bowels,  c^c.  p.  72. 

*  Vol.  II.  p.  256,  Am.  Ed. 


ENTERITIS.  595 

not  only  a  practical,  but  confessedly,  a  systematic  writer.  Gre- 
gory is  less  equivocal,  but  not  less  faulty  in  his  definition  of  en- 
teritis, as  he  locates  the  inflammation  on  the  external  coat;  thus 
confounding  peritoneal  inflammation  with  inflammation  of  the 
mucous  membrane  of  the  intestines;  a  mistake,  in  our  estima- 
tion, of  great  practical  importance.  For  we  have  endeavoured 
to  prove  under  the  head  of  "peritonitis,"  that  the  peritoneum 
may  be  inflamed,  even  to  the  destruction  of  life,  without  neces- 
sarily implicating  the  tissue  beneath  it. 

2010.  It  would  appear  from  the  observations  of  Dr.  Armstrong, 
that  the  serous  membrane  may  be  inflamed,  without  implicating 
the  mucous,  as  has  been  observed  in  peritonitis.     But  Dr.  A. 
does  not  call  this  condition  of  the  serous  membrane  peritonitis, 
except  it  assume  the  chronic  form.     We  fear  there  is  more  re- 
finement than  practical  utility  in  this  distinction,  and  especially 
as  the  symptomatology  is  very  much  the  same,  and  the  treatment 
perhaps  entirely  so.  But  as  we  have  much  confidence  in  Dr.  A. 
as  an  accurate  observer,  and  as  a  faithful  detailer  of  facts,  we 
think  it  best  to  let  him  speak  for  himself — we  shall  therefore 
quote  his  own  description  of  the  complaint,  which  he  terms 
"sero-enteritis;"  that  is,  an  inflammation  of  the  peritoneal,  or 
serous  covering  of  the  intestine. 

201 1.  "In  acute  sero-enteritis,  fairly  established,  there  is  con-  - 
siderable  fever.     The  skin  is  every  where  hotter  than  natural; 
often  dry  about  the  trunk,  and  at  the  same  time  moist  in  some 
of  the  extreme  parts  of  the  body,  but  especially  about  the  palms 
of  the  hands  and  the  forehead.  The  pulse  is  very  quick,  ranging 
generally  from  120  to  130  in  the  minute ;  it  is  always  very  small, 
as  if  not  only  the  heart,  but  the  artery  at  the  wrist  has  contract- 
ed upon  itself;  yet,  if  it  be  accurately  examined,  it  will  be  found, 
during  the  stage  of  excitement,  firmer  than  natural,  almost  feel- 
ing then  like  a  small  whip-cord  or  harp-string.     The  tongue  is 
covered  with  a  whitish  fur,  and  there  is  excessive  thirst.     The 
breathing  is  hurried  and  anxious,  and  yet  the  respiration  seems 
to  be  carried  on  by  the  diaphragm  and  intercostals,  the  abdomi- 
nal muscles  acting  less  than  in  the  healthy  state.     The  integu- 
ments of  the  belly  lose  their  natural  softness  and  pliability,  and 
are  hard  and  irregular  to  the  touch.   There  is  a  concentration  of 
heat  over  the  inflamed  region  of  serous  membrane,  and  both  pain 
and  tenderness  are  complained  of  there,  particularly  under  pres- 
sure, during  the  continuance  of  which  the  patient  winces- 
changes  the  expression  of  his  face  from  an  increase  of  pain.  The 
bowels  are  obstinately  constipated,  an  effect  of  the  inflammation 
of  the  serous  membrane,  which  is  unfortunately  too  often  treated 
as  the  cause  of  the  inflammation.  The  abdomen  is  tense  and  d;s« 
tended,  chiefly  from  the  generation  of  flatus  within,  of  which  the 


// 


596  ENTERITIS. 

patient  usually  complains  much.  If  .nausea  or  vomiting  should 
not  occur  in  the  commencement  of  the  attack,  they  are  almost 
sure  to  be  its  attendants  during  the  progress  of  the  inflammation, 
and  are  generally  the  most  urgent  in  the  worst  cases."*The  patient 
almost  always  lies  upon  his  back  with  his  legs  drawn  upwards,  as  if 
instinctively  to  relax  the  abdominal  muscles,  and  he  is  cautious 
in  moving  the  lower  extremities,  lest  he  should  increase  the  pain, 
while  he  mostly  moves  the  upper  more  frequently  than  natural; 
and  in  bad  cases  often  dashes  down  the  hand,  or  lets  it  abruptly 
fall  upon  the  bed-clothes.  The  urine  is  scanty  and  high-colour- 
ed, as  it  is  in  almost  all  serous  inflammations."  Dr.  A.  makes 
two  stages  of  this  disease.  One  of  exalted  action  or  excitement, 
and  the  other  of  collapse  —  the  first  is  usually  preceded  by  rigour 
or  chilliness,  which  is  followed  by  much  heat  or  excitement.  He 
says,  "in  the  stage  of  excitement,  the  skin  is  uniformly  hotter 
than  natural,  except  in  those  parts  which  are  moist,  and  exposed 
to  the  air,  and  then  the  evaporation  makes  them  rather  cool,  a 
circumstance  which  should  be  remembered,  because  I  have  known 
hasty  observers  conclude  from  it  alone,  that  the  fatal  stage  of 
collapse  was  at  hand,  when  in  reality  it  was  very  far  distant. 
During  the  stage  of  excitement,  too,  the  pulse,  though  smaller, 
is  always  more  resisting  than  natural  ;  the  respiration  is  not  em- 
barrassed, but  merely  quick  and  anxious;  the  countenance  has 
not  a  sunken  character,  and  the  patient  continues  to  complain  of 
the  abdominal  pain. 

2012.  "Whereas  in  the  stage  of  collapse,  the  heat  fails  every 
where,  first  on  the  extremities,  and  then  upon  the  trunk,  the  skin 
becoming  of  a  clayey  coldness  and  dampness  at  last,  while  the 
fingers  and  hands  are  generally  mottled  by  a  dun  sort  of  redness 
here  and  there.  The  pulse  becomes  quicker,  smaller,  and  is  now 
really  weak,  feeling  like  a  soft  undulating  line.  The  respiration 
Js  embarrassed  even  to  exhaustion;  the  whole  muscular  power  is 
prostrate  ;  the  face  is  sunk,  and  especially  hollow  round  the  or- 
bits; the  abdomen  grows  more  and  more  tumid  and  tense,  while 
the  pain  mostly  lessens,  or  sometimes  entirely  leaves  the  patient; 
and  lastly,  a  sort  of  passive  gulping  generally  takes  place,  the 
contents  of  the  stomach  being  apparently  forced  up  the  esopha- 
gus by  the  pressure  of  the  intestines,  which  are  then  for  the  most 
part  enormously  distended  by  flatus.     In  this  state,  the  patient 
sinks  almost  always  with  a  collected  mind  in  common  sero-en- 
teritis,  and  sometimes  even  speaks  confidently  of  recovery,  when 
all  hopes  have  been  extinguished  in  the  practitioner."*  —  Morbid 
Jlnatomy,  fyc.  p.  93. 

2013.  In  this  history  we  must  repeat,  that  we  see  nothing  but 

*  See  Yellow  Fever. 


/\  I  /  At"      " 

*  Mj/t 

•* 


ENTERITIS.  597 

a  case  of  peritoneal  inflammation,  modified  perhaps  by  sex  and 
the  influence  of  the  remote  causes.  And  we  cannot  fail  to  remark 
here,  the  great  similarity  in  the  state  of  the  mind  in  sero-enteri- 
tis,  and  that  form  of  gastritis  called  yellow  fever. 

2014.  But  notwithstanding  the  obvious  similarity  in  the  tissue 
affected  in  peritonitis  and  sero-enteritis,  Dr.  A.  contends  that  the 
former  term  is  vaguely  used,  and  that  there  is  really  a  difference 
between  these  two  affections.  Dr.  A.  observes,  "when  acute 
peritonitis,  as  above  explained,  occurs,  (namely,  the  portion  of 
this  membrane  confined  to  the  abdominal  parietes,)  it  may  be 
distinguished  from  acute  sero:enteritis,  by  the  following  symp- 
toms ;  namely,  in  acute  peritonitis  the  pain  is  diffused  over  the 
whole  belly ;  whereas  in  sero-peritonitis  it  is  mostly  limited  to 
some  particular  part  of  that  region.  In  acute  peritonitis  the  skin 
is  not  only  hotter,  but  the  pulse  is  more  expanded  than  in  acute 
sero-enteritis.  Finally,  nausea,  retching,  and  vomiting,  are  far 
more  apt  to  appear  at  an  early  stage  of  acute  sero-enteritis,  than 
of  acute  peritonitis.  If  any  case  should  take  place,  in  which  the 
pain  and  tenderness  are  universally  diffused  over  the  belly  from 
the  beginning,  in  which  the  pulse  is  small  as  well  as  hard,  and 
in  which  vomiting  has  been  a  prominent  sign  from  the  onset,  it 
may  be  concluded,  either  that  a  very  large  portion  of  the  serous 
membrane  of  the  bowels  is  inflamed,  or  that  a  less  portion  is  in- 
flamed conjointly  with  a  considerable  one  of  the  peritoneum 
lining  the  abdominal  muscles."  p.  95. 

2015.  Notwithstanding  the  apparent  accuracy  of  these  distinc- 
tions, we  are  warranted  from  experience  to  declare,  that  none  of 
the  enumerated  signs  are  unequivocal  proofs  of  the  conditions 
detailed  by  Dr.  A.     We  have  lately  seen  a  remarkable  illustra- 
tion of  the  truth  of  this  remark.  A  lady  with  a  first  child,  com- 
plained on  the  third  day  after  delivery  of  considerable  tenderness 
of  the  abdomen  immediately  over  the  uterine  region,  for  which 
leeches  were  applied,  and  purging  instituted ;  the  pulse  was  fre- 
quent, but  not  tense;  the  skin  was  only  moderately  warm;  there 
was  neither  nausea  nor  vomiting.     After  the  application  of  the 
leeches,  we  were  assured  by  her  physician  there  was  no  tender- 
ness, or  painful  sensation  upon  pressure  in  any  portion  of  the  ab- 
domen.   She  died,  however,  on  the  seventh  day.    Leave,  at  our 
suggestion,  was  obtained  to  inspect  the  body,  which  was  done 
eighteen  hours  after  death.    The  abdomen  was  not  much  swoln ; 
within  its  cavity,  there  was  a  considerable  quantity  of  effused 
serum,  and  large  portions  of  coagulated  lymph  floating  in  the 
fluid  as  well  as  attached  to  the  abdominal  parietes,  and  nearly 
over  the  whole  of  the  intestinal  surface,  together  with  several 
pretty  firm  adhesions  of  the  bowels  with  each  other. 

2016.  Now  in  this  case,  there  was  an  absence  of  all  the  lead- 


598  ENTERITIS. 

ing  diagnostic  signs  laid  down  by  Dr.  A.  and  the  presence  of  one 
or  two,  which  militate  against  his  distinctions.  First,  there  was 
universal  peritoneal  inflammation,  agreeably  to  his  definition  of 
peritonitis,  with  local  and  limited  tenderness.  Second,  there  was 
neither  nausea  nor  vomiting,  though  there  was  general  "  sero- 
enteritic"  inflammation. 

2017.  Enteritis,  like  almost  all  the  other  phlegmasiae,  may  be 
divided  into  the  acute  and  chronic.* 

Causes  of  Acute  Enteritis. 

2018.  The  intestinal  canal,  like  any  other  portion  of  the  body, 
may  become  the  seat  of  inflammation,  from  any  of  the  general 
causes  capable  of  producing  this  condition  of  a  part.   But  besides 
these,  it  may  have  others,  which  act  directly  upon  it.   Such  may 
be  poisons,  or  other  acrid  substances;  the  employment,  and  over- 
doses of  acrid  cathartic  medicines,  as  scammony,  colocynth,  ela- 
terium,  gamboge,  &c.;  highly  stimulating  potions,  as  the  too  free 
use  of  alcoholic  liquors;  mechanical  irritations  from  foreign  bo- 
dies; great  accumulation  of  hardened  fasces;  worms;  too  sudden 
application  of  cold,  when  the  body  is  heated,  either  to  the  intes- 
tinal surface,  or  to  that  of  the  skin ;  suppression  of  accustomed 
evacuations;  repelled  eruptions;  lying  on  damp  ground,  or  in 
damp  beds,  &c.  &c. 

Symptoms. 

2019.  This  complaint  is  sometimes  ushered  in  by  a  chill  of 
more  or  less  violence;  at  other  times  no  coldness  is  perceived; 
pain  in  the  abdomen  of  an  extremely  acute  kind,  and  without 
any  or  with  very  little  abatement;  this  either  limits  itself  to  a 
point,  or  it  is  spread  over  the  whole  abdominal  surface.     The 
belly  becomes  swelled,  and  so  sensible,  that  it  can  bear  with  dif- 
ficulty the  slightest  touch,  not  even  the  weight  of  the  bed-clothes. 
Sometimes  a  sensation  of  heat  is  observed  in  a  particular  portion 
of  the  abdomen  ;  a  sensation  of  twisting  is  felt  about  the  umbili- 
cus; the  patient  finds  most  comfort  by  lying  on  his  back,  and 
always  experiences  pain  in  every  attempt  to  move  his  position ; 
sometimes  he  feels  momentary  relief  from  lying  on  his  belly; 
and  with  a  hope  of  obtaining  some  abatement  of  pain  from  change 
of  posture,  he  is  almost  constantly  tossing  himself  to  and  fro, 
without  finding  the  relief  he  had  hoped  for,  and  he  so  much 
needs,  and  at  the  same  time  subjecting  himself  to  fresh  torture, 
by  each  change  of  position. 

*  See  Peritonitis. 


ENTERITIS.  599 

2020.  Sometimes  the  inflammation  is  confined  to  one  o£  the 
intestines,  or  even  to  a  portion  of  one;  in  this  case,  the  inflamed 
part  usually  becomes  distended,  and  an  elastic  tumour  of  the 
shape  of  the  intestine  may  be  seen  or  felt  through  the  abdominal 
parietes.  Costiveness,  nausea,  vomiting  of  porraceous  matter,  or 
diarrhoea,  now  succeed.   If  diarrhoea  supervene,  the  character  of 
the  discharges  may  vary  frequently  during  the  course  of  the  dis- 
ease; sometimes  they  will  consist  of  a  white  or  gray  mucus; 
sometimes  serous,  bloody,  yellow,  or  green,  and  the  discharge 
is  sure  almost  to  be  accompanied  by  a  discharge  of  flatus,  cutting 
pains,  or  tenesmus. 

2021.  The  fever  generally  augments  for  some  time,  or  at  least 
suffers  no  abatement;  insupportable  thirst,  with  dryness  of  mouth 
and  a  bitter  taste;  disgust  for  food;  breathing  hurried;  anxiety; 
watchfulness;  pulse  small  and  irregular;  head-ache;  giddiness; 
stupor;  delirium;  hiccup;  cold  extremities ;  burning  abdomen; 
involuntary  and  frequent  stools  of  highly  offensive  odour,  putrid, 
cadaverous;  but  little  urine,  and  that  high-coloured  and  rendered 
with  pain,  sometimes  an  entire  suppression.     In  all  cases  the 
strength  fails  rapidly,  and  the  patient  soon  arrives  at  a  hopeless 
stage;  or  a  favourable  change  may  unexpectedly  manifest  itself, 
or  it  may  slowly  degenerate  into  a  chronic  form.     This  disease 
runs  its  course  rapidly,  either  for  a  fortunate  or  for  a  fatal  issue — 
its  duration  rarely  exceeds  two  weeks ;  it  frequently  terminates 
in  one,  or  even  in  a  shorter  time. 

2022.  As  topical  means  are  highly  important  in  this  disease, 
it  is  of  considerable  practical  importance  to  determine  as  nearly 
as  possible  the  seat  of  the  inflammation,  that  remedies  may  be 
applied  with  a  greater  chajice  of  success.  This  is  sometimes  very 
much  in  our  power;  for  by  tracing  the  symptoms  to  the  patho- 
logical appearances  revealed  by  dissections,  it  has  been  found 
that  different  phenomena  present  themselves,  as  it  may  be  the 
great  or  small  intestines  that  are  implicated  in  the  inflammation; 
thus  when  the  mucous  membrane  of  the  great  intestines  is  the 
seat,  we  find  frequent  and  copious  dejections,  with  distressing 
tenesmus;  when  it  is  the  small,  we  have  great  nausea  and  severe 
vomitings,  with  a  more  obstinate  constipation. 

2023.  It  may  also  be  well  to  observe,  that  the  vomiting  be- 
comes more  frequent  and  obstinate,  as  the  inflammation  may  ap- 
proach the  stomach  itself;  for  the  intensity  of  its  sympathy  with 
the  mucous  membrane,  is  augmented  by  proximity.    A  hepatitis 
may  be  similated,  when  the  colon  is  the  phlogosed  part;  if  the 
rectum  be  the  seat  of  the  disease,  haemorrhoids  may  ensue  with 
a  permanent  tenesmus,  and  perhaps  strangury.* 

*  Rcnauldin,  Diet,  des  Scien.  Med.  Art.  Entente. 


600  ENTERITIS. 

2024.  Though  it  is  satisfactorily  proved,  that  the  tissue  cover- 
ing a  part  may  be  exclusively  the  seat  of  inflammation,  yet  it 
does  not  follow,  that  it  shall  be  limited  to  it  under  all  circum- 
stances— hence,  we  sometimes  find  the  several  structures  com- 
posing a  part,  successively  involved ;  thus  the  mucous  membrane 
of  an  intestine  may  be  the  original  seat  of  inflammation ;  yet  this 
inflammation  may  be  transmitted  to  the  serous  membrane,and  then 
a  complication  of  enteritis  and  peritonitis  may  thus  be  formed;  or 
this  may  be  reversed.    Again,  when  the  peritoneum  becomes  in- 
flamed in  consequence  of  its  contiguity  or  sympathy,  with  the  mu- 
cous membrane  in  enteritis,  it  may  communicate  its  condition  to 
other  portions  of  itself,  and  by  this  means  involve  the  viscera 
which  it  covers — hence,  any  of  the  abdominal  viscera  may  indi- 
rectly become  affected. 

2025.  Experience  has  fully  confirmed  these  observations ;  it 
therefore  becomes  sometimes  a  matter  of  consequence  to  deter- 
mine the  precise  or  original  seat  of  the  disease,  that  one  affection 
may  not  be  mistaken  for  another.     Thus,  the  colon  being  in- 
flamed may  give  rise  to  symptoms  similar  to  hepatitis ;  as  there 
may  be  pain  and  soreness  in  the  right  side ;  but  it  should  be  re- 
collected that  in  this  disease,  there  are  many  other  symptoms 
necessary  to  constitute  hepatitis.     That  in  gastritis,  it  is  the  re- 
gion of  the  stomach  that  is  painful;  vomiting  solids  and  fluids  im- 
mediately after  having  been  swallowed,  &c.     In  a  word,  there 
should  be  all  the  usual  symptoms  which  belong  to  the  imposed 
or  secondary  disease  ;  and  if  these  be  not  present,  and  the  signs 
belonging  to  enteritis  are,  we  have  then  the  stronger  reason  to 
suppose  it  to  be  this  disease. 

2026.  We  have  already  remarked  that  enteritis  generally  ran 
its  course  with  considerable  rapidity,  especially  when  it  was 
about  to  terminate  either  favourably  or  fatally.     That  the  first 
may  take  place,  it  requires  that  the  parts  affected  shall  not  have 
received  a  shock  so  severe,  as  to  'be  beyond  the  recuperative 
powers  of  the  system,  when  aided  by  the  best  adapted  means. 
To  protect  the  one,  and  to  secure  the  other,  timely  and  well-pro- 
portioned means  must  be  employed;  and  when  a  cure  is  effected, 
it  is  by  a  resolution  of  the  inflammation;  if  this  be  perfect,  health 
will  be  restored  ;  if  it  be  not,  the  patient  may  experience  for  a 
long  time  a  number  of  inconveniences  of  greater  or  less  magni- 
tude; such  as  an  obstinate  costiveness,  or  an  habitual  diarrhoea; 
swelling  of  the  belly,  flatulency,  and  a  persevering  debility. 

2027.  When  death  takes  place,  it  is  most  commonly  by  gan- 
grene— this  termination  is  usually  preceded  by  a  number  of 
well-marked  and  not  easily  to  be  mistaken  symptoms.     Pain 
ceases  suddenly,  however  violent  it  may  have  been  previously ; 
the  extremities  become  cold,  and  the  wrists  especially;  cold 


ENTERITIS.  601 

sweat;  hiccup;  vomiting  of  dark  matter;  convulsions  sometimes, 
and  death.  Renauldin  says,  cures  have  taken  place  even  after 
the  gangrene  of  a  portion  of  the  intestine. 

2028.  There  is  a  third  termination  of  enteritis;  its  becom- 
ing chronic   by  the  abatement  of  the  inflammation,   but  not 
by   its   entire    extinction.       This    only   takes   place   however 
where  the  inflammation  has  successively  passed  through  the  se- 
veral tissues  which  compose  the  intestines,  and  the  peritoneal 
or  serous  coat  throwing  out  coagulable  lymph,  and  thus  produc- 
ing adhesions  with  each  other  by  the  formation  of  a  false  mem- 
brane.    Or  ulceration  may  take  place,  and  thus  form  a  commu- 
nication between  the  bowel  and  abdomen. 

2029.  When  enteritis  is  about  to  become  chronic,  a  slow  fever 
commences;  it  is  preceded  by  frequent  and  slight  chills,  which  are 
always  succeeded  by  heat  and  dry  skin,  which  generally  augment 
towards  evening.     The  pulse  is  frequent  and  small;   there  is 
almost  always  a  dull  pain  in  the  abdomen,  &c.  together  with 
all  the  symptoms  almost  laid  down  for  chronic  peritonitis,  which 
see,  page  557. 

2030.  Examinations  after  death,  distinctly  locate  the  disease, 
and  also  declare  its  nature.     The  mucous  membrane  is  found  to 
be  its  seat,  by  being  inflamed,  and  very  red  in  consequence  of 
the  increased  size  of  the  sanguineous  capillaries  which  enter  into 
its  structure.     Sometimes  patches  of  extravasated  blood ;  and 
sometimes  the  peritoneal  coat  is  also  found  involved,  especially 
when  the  mucous  membrane  is  highly  inflamed ;  in  this  case,  we 
find  layers  of  coagulable  lymph  spread  upon  this  membrane. 
The  intestine  is  generally  found  thickened,  and  very  black,  in 
consequence  of  the  extravasation  of  venous  blood,  which  is  some- 
times mistaken  for  a  gangrene  of  the  part.   Gangrene,  which  also 
happens,  as  we  have  said,  (par.  2027,)  may  be  distinguished  from 
this  extravasation,  by  the  lividity  of  its  colour,  and  the  facility 
with  which  its  continuity  is  destroyed.  When  gangrene  has  pro- 
duced openings  into  the  abdomen,  we  find  a  quantity  of  faecal 
matter  within  this  cavity,  which  distinctly  points  out  the  nature 
of  the  communication  between  these  two  parts. 

2031.  In  making  up  our  minds  upon  the  probable  event  of 
acute  enteritis,  we  must  constantly  keep  in  view  the  nature  of 
the  causes  which  have  produced  it;  regarding  poisons,  acrid  sub- 
stances, intus-susception,  and  strangulated  hernia,  as  the  most 
dangerous  causes ;  and  consequently  the  termination  of  the  dis- 
ease that  either  may  have  produced,  is  less  frequently  favourable 
than  from  other  causes.     If  the  disease  be  secondary,  or  metas- 
tatic,  the  prognosis  may  be  more  favourable,  as  the  disease  with 
which  the  intestine  has  sympathized,  may  be  capable  of  cure,  and 
thus  relieve  the  other. 

76 


602  ENTERITIS. 

2032.  The  violence,  or  moderation  of  the  symptoms,  will  also 
enable  us  to  form  an  estimate  of  the  danger;  for  in  proportion  to 
the  intensity  of  these,  will  be  the  risk.     A  diarrhoea  is  more 
favourable  than  constipation  ;  especially  if  vomiting  accompany 
the  latter;  for  the  former  may  be  looked  upon,  if  not  too  severe, 
as  rather  useful ;  and  not  absolutely  bad  if  the  stools  be  even 
bloody.    Enteritis  is  more  manageable  when  it  confines  itself  to 
the  mucous  membrane  of  the  large  intestines,  than  when  the  in- 
flammation occupies  the  small  intestines,  and  involves  their  ex- 
ternal or  peritoneal  coat. 

2033.  The  cessation  of  pain  without  adequate  cause;  or  the 
abatement  of  symptoms;  the  smallness  and  inequality  of  the  pulse; 
cold  sweats ;  sharp,  acrid,  thin,  black  stools ;  or  discharging  them 
involuntarily;  great  swelling  of  the  abdomen;  hiccup;  dry  tongue; 
delirium ;  loss  of  vision ;  fainting,  &c.  must  be  looked  upon  al- 
most necessarily  as  fatal  symptoms.  While,  on  the  contrary,  we 
may  regard  a  diminution  of  the  pains,  both  in  frequency  and  vio- 
lence; sinking  of  the  tumefaction  of  the  abdomen  in  a  gradual 
and  regular  manner ;  stools  becoming  less  frequent,  and  less  fetid; 
increase  of  urine ;  thirst  lessening;  and  strength  rather  renewing; 
as  favourable,  and  promising  a  happy  issue. 

Treatment. 

2034.  The  treatment  of  enteritis  should  consist  in  attempts  to 
remove  inflammation,  and  assuage  pain. 

2035.  The  first  is  to  be  done  by  the  free  abstraction  of  blood 
from  the  arm ;  nor  need  we  be  sparing,  as  it  is  the  only  means 
by  which  we  can  make  an  impression  upon  the  disease.     We 
cannot  declare  in  round  numbers  the  quantity  to  be  abstracted;  it 
must  be  permitted  to  flow  until  a  sensible  alteration  takes  place 
in  the  pulse — that  is,  until  its  force  is  so  much  abated,  as  to  seem 
to  flutter  under  the  finger.  This  in  certain  constitutions  happens 
very  soon ;  but  rather  from  idiosyncrasy,  than  from  the  absolute 
effects  of  the  bleeding  independently  of  this  peculiarity,  and  be- 
fore it  would  seem  that  the  quantity  drawn  can  have  effected  a 
favourable  change  in  the  inflamed  part.     If  this  be  so,  we  should 
stop  the  bleeding,  and  permit  the  patient  to  recover  himself,  be- 
fore we  repeat  this  operation ;  for  in  such  constitutions  we  have 
constantly  observed,  that  the  same  advantages  were  obtained 
from  this  approach  to  syncope,  as  if  this  condition  were  the  re- 
sult of  a  large  quantity  of  blood — therefore,  xve  are  not  to  be 
regulated  by  the  measurement  of  the  blood,  but  by  the  effects  its 
abstraction  may  have  upon  the  circulating  system. 

2036.  We  must,  however,  in  either  case  again  have  recourse 
to  the  lancet  so  soon  as  the  system  again  reacts,  if  pain  be  not 


ENTERITIS.  003 

moderated,  or  if  it  shall  again  become  severe.  In  inflammations 
of  the  bowels,  the  continuance  of  pain  seems  to  be  a  better  direc- 
tion for  the  further  loss  of  blood,  than  the  pulse ;  and  this  is  true, 
whichever  tissue  may  be  diseased ;  we  have  very  constantly  acted 
upon  this  principle  for  the  last  forty  years.  For  we  were  very 
early  taught  the  value  of  this  rule,  by  being  placed  in  a  neigh- 
bourhood where  dysentery  was  sure  to  be  rife  every  autumn ; 
and  where  we  saw  for  several  years  consecutively,  at  least  five 
hundred  patients  annually  in  this  complaint. 

2037.  We  were  directed  to  this  mode  of  practice,  first,  from 
the  pathology  of  the  disease ;  second,  from  finding  it  almost  the 
only  remedy  that  afforded  relief;  and  third,  from  observing  that 
many  died,  when  this  remedy  was  not  sufficiently  used.     For  it 
should  be  constantly  kept  in  mind,  that  there  is  no  portion  per- 
haps of  the  system,  that  sustains  violent  inflammation  so  ill,  or 
that  succumbs  so  speedily  under  it,  as  the  alimentary  canal. 

2038.  In  aid  of  the  general  bleeding,  we  should  direct  the  most 
determined  antiphlogistic  regimen — all  food  should  be  prohibited; 
and  nothing  but  the  most  bland  articles  of  drink  should  be  em- 
ployed— these  should  consist  of  barley  water,  rice  water,  gum 
water,  weak  slippery-elm  bark  tea,  toast  tea,  or  flaxseed  tea.  We 
are  aware  that  the  friends  of  the  patient  often  become  clamorous 
for  food  upon  such  occasions ;  but  a  deaf  ear  should  be  turned  to 
every  importunity ;  for  compliance,  is  but  sealing  the  fate  of  the 
patient.  Ice  water,  and  ice  itself  are  often  found  highly  grateful, 
as  well  as  decidedly  useful ;  especially  where  there  is  vomiting 
or  much  nausea ;  for  thirst  can  be  gratified  by  a  very  small  bulk 
of  fluid,  without  incurring  the  risk,  that  filling  the  stomach  con- 
stantly exposes  the  patient  to — for  it  should  be  ah  invariable  rule, 
where  the  symptoms  just  named  are  present,  not  to  put  much  of. 
any  thing  into  -the  stomach. 

2039.  The  bowels  should  be  opened,  by  small  and  repeated 
doses  of  castor  oil,  or  by  either  of  the  neutral  salts,  in  divided 
portions ;  these  may  be  aided  by  injections  of  any  of  the  muci- 
laginous teas ;  depending  upon  their  bulk,  rather  than  upon  their 
stimulus  for  their  operation.    If  diarrhoea  attend,  it  is  found  use- 
ful to  give  the  (jastor  oil  as  suggested  above,  unless  the  stools  are 
watery  and  acrid,  and  their  discharge  attended  by  much  effort, 
and  flatulency.     In  this  case  the  mild  injections  in  small  quanti- 
ties may  be  exhibited  every  two  or  three  hours  with  advantage- 
thin  starch  or  arrow  root,  answer  extremely  well  for  this  pur- 
pose.    Though  we  have  directed  gentle  purging,  from  a  convic- 
tion of  its  usefulness,  we  nevertheless  condemn  in  the  strongest 
terms,  active  purging;  especially  when  produced  by  the  more 
active  and  acrid  of  the  cathartics — we  therefore  unhesitatingly 
disapprove  of  this  part  of  the  treatment  of  enteritis,  as  laid  down 


604  ENTERITIS. 

by  Dr.  Good.  The  French  condemn  this  practice  altogether,  at 
this  moment — at  least  such  as  belong  to  the  physiological  school; 
this  we  look  upon  as  ultra-theory,  as  well  as  ultra-practice,  and 
is  perhaps,  as  reprehensible  as  the  purging  plan. 

2040.  In  this  entire  proscription  of  cathartics,  it  seems  to  be 
lost  sight  of,  that  as  powerful  an  irritant  is  left  within  the  bowels, 
if  it  be  not  carried  off  by  the  employment  of  laxatives;  and  that 
this  acrid  mass  accumulates  in  proportion  to  the  tardiness  of  the 
bowels.    We  look  upon  several  of  the  affections  of  the  alimentary 
canal,  as  having  their  origin  in  the  inflammation  or  irritation  of 
its  mucous  membrane,  (or  its  follicles,)  as  diarrhoea,  cholera, 
and  dysentery,  and  in  the  treatment  of  which,  almost  all  experi- 
ence is  in  favour  of  mild  cathartics,  or  the  more  simple  laxatives — 
who  has  not  seen  diarrhrea  put  a  stop  to,  by  a  single  dose  of  cas- 
tor oil ;  cholera  suspended  by  a  few  minute  doses  of  calomel ; 
and  dysentery  arrested,  by  a  repetition  of  the  milder  eccoprotics? 
If  this  be  true,  what  have  we  to  fear  from  the  judicious  selection, 
or  the  proper  use  of,  these  remedies  in  enteritis? 

2041.  Leeching  in  this  disease,  is  a  powerful  auxiliary;  and 
should  be  resorted  to,  again  and  again,  if  pain  continue;  the  part 
of  the  abdomen  to  which  they  are  to  be  applied,  must  be  directed 
in  some  measure  by  the  pain  itself — choosing  such  places  in 
which  it  is  most  intense,  in  preference  to  a  more  diffused  appli- 
cation of  them.     Their  bites  may  be  encouraged  to  bleed  by  the 
application  of  a  piece  of  fine  flannel,  wrung  out  of  warm  flax- 
seed  tea,  to  the  punctured  surface. 

2042.  When  hemorrhoids  attend,  or  it  is  the  large  intestines 
that  are  inflamed,  the  French  practitioners  recommend  in  very 
high  terms  the  application  of  leeches  to  the  anus — from  our  own 
experience,  we  can  say  but  little  of  their  efficacy  when  used  to 
this  part;  as  we  have  not  been  able  to  get  the  patient  to  submit 
to  it  but  in  one  instance ;  in  this  case  it  appeared  to  be  very 
useful. 

2043.  We  have  thought  that  much  comfort  and  advantage 
has  been  derived  from  the  occasional  use  of  the  warm  bath 
when  the  weather  has  been  warm — when  cold,  we  have  feared 
to  recommend  it,  lest  the  process  should  not  be  conducted  with 
a  caution  sufficient  to  protect  the  patient  against  injury  from  its 
employment. 

2044.  Opium  should  be  entirely  forbidden  during  the  active 
stage  of  enteritis — we  fear  much  mischief  has  been  done  by  an 
unguarded  use  of  this  drug;   attempting  by  it  to  overcome  a 
pain,  that  can  only  be  relieved  by  the  lancet.     But  after  due 
depletion  has  been  performed,  it  may  be  had  recourse  to  with  ad- 
vantage in  the  form  of  an  enema — we  direct  a  gill  of  flaxseed  tea, 
or  thin  starch,  and  from  forty  to  sixty  drops  of  laudanum  to  be 


COLIC.  605 

administered  at  bed-time,  or  even  during  the  day,  if  the  pain  be 
great,  the  pulse  sufficiently  reduced,  and  the  bowels  open. 

2045.  Of  the  treatment  of  chronic  enteritis  we  can  say  no- 
thing that  is  encouraging — a  pro  re  nata  treatment  is  all  that 
can  be  resorted  to ;  namely,  the  occasional  use  of  opium  ;  keep- 
ing the  bowels  open  by  the  gentlest  means;  diluent  and  mucila- 
ginous   drinks;    a  well-regulated  diet,  suited  to  the  digestive 
powers  of  the  stomach,  or  its  peculiarities,  and  the  total  disuse 
of  all  ardent,  or  fermented  liquors,  is  the  sum  of  our  means  we 
believe,  in  this  almost  always  fatal  disease. 

2046.  We  have  said  nothing  of  blisters  in  our  history  of  the 
treatment  of  enteritis — we  omitted  them,  because  we  have  never 
been  satisfied  of  their  utility  in  any  instance;  and  our  impres- 
sion decidedly  is,  that  they  are  hurtful  in  every  active  inflam- 
mation of  the  membranous  tissues  of  the  abdominal  viscera.  * 

SECT.  VI. — COLIC. 

2047.  A  good  deal  of  latitude  is  given  to  this  word;  it  is  made 
to  signify  almost  any  acute  pain  in  the  abdomen  or  intestinal 
canal,  especially  if  it  observe  alternate  increase  and  diminution. 
It  is  true,  that  each  variety  of  this  affection,  be  its  seat  or  its  cause 
ever  so  different,  has  something  in  common  with  the  rest.  Hence 
all  who  may  be  afflicted  with  this  complaint,  experience  pain  of 
greater  or  less  severity,  or  of  longer  or  shorter  duration,  about 
the  navel.     The  character  of  the  pain  however,  differs  a  little  as 
its  remote  cause  may  differ;  one  patient  may  represent  it  as  a 
twisting  sensation  in  the  bowels ;  while  another  will  describe  it 
as  a  sensation  from  distention.     Wind  is  heard  to  pass  from  one 
portion  of  the  intestines  to  another ;  the  patient  tosses  himself 
about  from  place  to  place ;  sometimes  he  anxiously  solicits  pres- 
sure upon  the  abdomen,  at  other  times  he  cannot  bear  the  slight- 
est touch.     Sensations  of  cold  are  experienced  in  various  parts 
of  the  body ;  but  especially  the  feet  and  legs.     If  the  disease  be 
violent,  the  pulse  is  small,  slow,  or  unusually  frequent,  or  ex- 
tinct; in  this  case,  the  face  is  pale,  the  features  shrunk,  and  the 
whole  body  covered  with  cold  sweat.     The  bowels  are  almost 
always  costive;  though  occasionally  there  may  be  diarrhoea ;  nau- 
sea almost  always  attends,  frequent  belchings  of  wind,  of  various 
tastes,  and  sometimes  vomiting. 

2048.  The  symptoms  just  detailed,  are  for  the  most  part  com- 
mon to  all  colics;  yet  each  variety  seems  to  have  its  own  charac- 
ters, though  they  are  not  always  so  strongly  marked  as  to  remove 
all  doubt  for  which  variety  we  are  obliged  to  prescribe.  The  em- 
barrassment created  by  this,  is  not  however  always  of  great  con- 
sequence, as  a  general  mode  of  treatment  is  necessary,  be  the 


606  COLIC. 

cause  of  the  variety  what  it  may.  We  shall  however  for  the 
better  understanding  of  the  nature  of  each,  divide  them  into, 
1,  the  crapulous  or  flatulent  colic;  2,  the  bilious  colic ;  3,  the 
ileus,  or  dry  belly-ache ;  4,  the  painter's, colic  or  the  colic  arising 
from  lead. 

I.   Crapulous,  or  Flatulent  Colic. 

2049.  This  colic  most  frequently  arises  from  either  too  much 
food  being  taken  into  the  stomach  at  one  time,  and  thus  pro- 
ducing indigestion;  or  the  quality  of  the  food  may  not  be  suitable 
to  the  condition  of  the  stomach.     In  both  instances,  there  may 
be  a  great  extrication  of  gas;  so  much  so  sometimes,  as  to  distend 
the  stomach  and  bowels  enormously,  and  to  create  not  only  the 
severest  sufferings,  but  also  the  most  alarming  symptoms.     The 
causes  of  colic  in  these  instances,  are  sufficiently  palpable,  and 
may  always  be  detected  by  proper  inquiry  into  the  nature  and 
the  quantity  of  the  substances  taken  into  the  stomach;  but  occa- 
sionally we  have  seen  this  colic  produced  without  any  fault  in 
either  the  quantity  or  quality  of  the  ingesta.     This  appears  to 
arise  from  some  condition  of  the  nervous  system,  as  it  is  almost 
always  preceded  by  some  moral  cause,  of  a  distressing  or  vexa- 
tious kind. 

2050.  This  last  form  of  flatulent  colic,  we  have  seen  take 
place  in  the  course  of  a  few  minutes,  and  be  attended  by  a  suite 
of  the  most  alarming  symptoms;  the  stomach  and  bowels  have 
been  violently  distended;  creating  the  most  intense  suffering, 
and  exciting  the  most  just  apprehensions.    We  attended  a  lady, 
for  many  years,  who  was  subject  to  this  kind  of  colic;  in  her  it 
was  always  produced  from  her  mind  having  been  disturbed  in 
one  way  or  other  previously.     In  this  case  the  symptoms  were 
so  violent  sometimes  as  to  threaten  immediate  death — we  have 
seen  her  cold  as  marble,  pulse  extinct,  and  drenched  with  ice- 
cold  sweat.     She  was  however  almost  always  relieved  by  the 
same  remedies — namely,  a  large  warm  sinapism  to  the  stomach, 
which  was  suffered  to  produce  considerable  irritation;  one  to 
each  leg,  and  a  tea-spoonful  of  Hoffman's  anodyne  liquor,  re- 
peated once  in  twenty  minutes  or  half  an  hour,  until  gas  began 
to  escape  from  the  mouth;  and  this  would  take  place  when  the 
spell  was  about  to  terminate,  in  surprising  torrents,  until  the 
stomach  appeared  quite  empty  and  relieved.     But  it  required 
several  such  discharges  before  the  paroxysm  would  cease,  for  one 
secretion  and  discharge  of  gas,  (for  such  it  appeared  to  be,)  would 
follow  another,  for  two  or  three  hours  together.     When  this 
affection  was  more  than  usually  obstinate,  much  advantage  was 
derived  from  an  enema  of  a  pint  of  water,  three  tea-spoonfuls  of 


COLIC.  607 


the  tincture  of  asafoetida,  and  as  much  of  the  spirit  of  turpentine; 
this  was  sure  to  procure  an  immediate  discharge  from  the  bowels 
of  flatus  and  faeces. 

Diagnosis. 

2051.  This  affection  cannot  well  be  confounded  with  any  other, 
as  its  remote  causes  are  almost  always  obvious — it  is  unlike  en- 
teritis, with  which  alone  it  can  be  confounded,  as  it  is  almost 
always  unattended  by  pyrexia;  by  the  pain  being  more  severe 
at  one  moment  than  at  another;  by  his  being  disposed  to  lie  upon 
his  belly,  or  even  able  to  bear  pressure,  and  by  the  frequent  dis- 
charges of  gas  from  the  mouth  by  belchings. 

Prognosis. 

2052.  This  disease  rarely  fails  to  terminate  favourably,  if  the 
patient  be  of  a  good  constitution.     But  if  the  stomach  be  fre- 
quently disturbed  by  indigestion,  or  its  powers  weakened  by 
over-stimulation,  it  may  prove  fatal,  by  inducing  chronic  inflam- 
mation.    Death  it  is  said  has  followed  the  sudden  and  excessive 
distention  of  the  stomach,  as  has  paralysis. 

Treatment. 

2053.  For  the  most  part,  this  disease  is  of  easy  management, 
requiring  but  little  more  than  a  free  evacuation  from  the  bowels 
by  castor  oil;  with  fifteen  or  twenty  drops  of  the  essence  of  pep- 
permint, or  a  tea-spoonful  of  Hoffman's  anodyne  liquor,  given 
two  or  three  times  if  the  pain  persist.     But  sometimes,  the  sto- 
mach requires  immediate  relief,  by  discharging  the  offending 
cause — when  produced  by  over-eating,  or  from  large  quantities 
of  crude  substances,  or  unripe  fruit,  a  few  grains  of  ipecacuanha 
so  as  to  cause  puking,  will  instantly  afford  relief;  especially,  if 
this  be  followed  by  a  dose  of  laudanum,  either  by  the  mouth,  or 
by  enema. 

II.  Bilious  Colic. 

2054.  This  affection  is  at  first  perhaps  seated  in  the  liver  it- 
self, as  it  is  always  preceded  by  symptoms,  which  if  they  do  not 
distinctly  declare  an  affection  of  this  organ  to  be  the  cause,  yet 
show  some  unusual  one  to  be  operating.     It  commonly  shows 
itself  during  the  prevalence  of  autumnal  complaints,  as  bilious 
fever,  diarrhoea,  cholera,  &c.     If  the  liver  itself  is  primarily  af- 
fected, and  that  it  is,  is  rendered  probable  by  the  season  of  the 


608  COLIC. 

year  at  which  this  colic  appears,  and  the  frequency  of  other  dis- 
eases, in  which  this  viscus  is  involved,  it  is  presumable,  that  the 
bile  itself,  has  been  secreted  not  only  in  an  acrid,  or  otherwise 
unhealthy  condition,  but  in  very  much  too  large  a  quantity. 
Now  if  either  of  these  conditions  obtain,  the  intestines  may  be 
thrown  into  spasm,  and  thus  produce  the  colic  in  question. 

Symptoms. 

2055.  Several  of  the  symptoms  which  mark  the  commence- 
ment of  this  colic,  are  precisely  those  which  usher  in  fever  in 
the  autumnal  months.     Such  as  head-ache,  nausea,  vomiting  of 
bile,  and  a  disagreeable  or  bitter  taste  in  the  mouth;  but  instead 
of  being  followed  by  a  distinctly  marked  fever,  the  bowels  show 
signs  of  being  unduly  stimulated,  or  irritated  by  the  presence  of 
some  offending  cause.      Griping  pains  are  felt  throughout  the 
belly,  a  sense  of  fulness  or  of  distention,  costiveness,  or  tenes- 
mus,  with  very  imperfect  evacuations.     Should  these  symptoms 
be  neglected,  or  not  be  removed  by  the  remedies  administered, 
fever  of  greater  or  less  force  is  pretty  sure  to  follow,  and  this  at- 
tended by  much  head-ache,  thirst,  lassitude,  and  pain  upon  any 
motion  that  will  exercise  the  abdomen.     The  tongue  is  foul,  the 
pulse  commonly  not  much  accelerated. 

2056.  We  have  occasionally  seen  a  well-marked  fever,  with 
considerable  tenderness  of  the  epigastrium  or  abdomen,  attend 
this  form  of  colic.     When  this  takes  place  however,  the  circula- 
tion is  rarely  equal;  for  the  feet  and  legs  are  sure  almost  to  be 
cold,  while  the  head  is  very  hot,  and  the  face  even  flushed. 

Treatment. 

2057.  There  are  few  diseases,  that  have  so  many  certain  cures, 
or  popular  remedies  as  colic;  most  of  which  are  of  a  highly  sti- 
mulating kind,  and  which  are  administered  with  a  most  liberal 
hand,  no  matter  how  improper  or  preposterous  they  may  be. 
There  are  few  evils  arising  out  of  vulgar  errors,  that  so  loudly 
call  for  redress,  as  the  domestic  treatment  of  colic — we  are  cer- 
tain we  have  seen  it  cause  death  in  more  instances  than  one.  The 
vulgar  should  be  taught  to  look  upon  this  disease  as  one  of  much 
danger,  and  always  requiring  nicety  of  management;  and  that 
the  administration  of  a  single  improper  remedy,  may  convert  a 
disease  of  comparative  simplicity,  into  one  of  complication,  and 
eventual  danger. 

2058.  The  indications  of  this  colic  must  be  derived  from  the 
state  of  the  pulse,  and  the  condition  of  the  bowels.     Should  the 
pulse  be  active,  and  other  signs  of  arterial  excitement  be  present, 


COLIC.  609 

the  patient  should  lose  blood  in  proportion  to  the  powers  of  the 
system,  and  the  force  of  the  disease.  If  there  be  tenderness  in 
the  epigastrium,  a  foul  tongue  with  red  edges,  if  there  be  nausea 
or  much  head-ache,  the  patient  should  lose  blood  immediately, 
either  by  the  arm,  or  from  leeches  over  the  region  of  the  sto- 
mach, though  the  pulse  be  not  very  active. 

2059.  If  the  bowels  be  costive,  care  should  be  taken  to  remove 
it  as  speedily  as  possible;  I,  by  cathartics;  2,  by  enemata;  3,  by 
blood-letting;  4,  by  warm  bath. 

-.    fflK^V     '••"Dl  '.r')noriJ  .iO 

1.  Cathartics.  • 

2060.  Cathartics  should  never  precede  blood-letting,  when  the 
latter  is  required,  if  it  be  practicable  to  command  it  pn  the  in- 
stant.    But  should  this  operation  not  be  indicated,  they  should 
be  given  forthwith.     As  we  believe  the  liver  to  be  always  more 
or  less  implicated  in  bilious  colic,  we  have  thought  much  advan- 
tage has  been  derived  by  first  giving  a  few  grains  of  calomel, 
(six  or  eight,)  letting  it  be  followed  by  some  milder  purgative, 
as  castor  oil,  or  magnesia  and  Epsom  salt.   Indeed,  we  may  even 
find  a  few  grains  of  jalap,  (twenty,)  a  very  proper  auxiliary  to 
the  calomel.     But  where  the. stomach  will  bear  the  castor  oil,  it 
is  decidedly  the  best  remedy  to  follow  the  calomel.    Much  mis- 
chief is  often  done  in  colic,  by  giving  large  doses  of  medicine  at 
a  time,  or  from  a  false  notion  that  the  very  active  or  even  dras- 
tic purgatives  are  required.     Our  rule  constantly  is,  to  give  small 
doses  of  the  milder  cathartics,  and  repeat  them  at  moderate  in- 
tervals, (once  an  hour,)  until  the  effect  is  produced.     Should  the 
stomach  be  so  much  exasperated  as  to  reject  every  thing  that  is 
offered,  we  should  not  increase  its  irritability,  by  presenting 
offensive  articles  to  it ;  but  a  brisk  injection  should  be  given 
immediately.     In  such  cases  we  should  give  nothing  for  a  time 
but  two  or  three  grain  doses  of  calomel,  once  an  hour,  until 
twelve  or  fifteen  grains  be  given — we  should  then  desist,  and 
have  recourse  to, 

2.  Enemata. 

2061.  These  should  be  made,  at  first,  pretty  stimulating;  a 
pint  of  warm  water,  and  a  table-spoonful  of  table  salt,  may  be 
given  with  great  and  speedy  advantage.     Should  the  first  fail,  a 
second  should  be  thrown  up  the  rectum,  in  fifteen  or  twenty 
minutes,  but  made  less  stimulating.  Should  these  not  prove  effi- 
cient, another  may  be  administered,  of  simple  flaxseed  tea,  fol- 
lowed by  a  second  or  a  third.    Should  these  remedies  be  unsuc- 
cessful, and  patient  continue  to  puke,  leeches  or  cups  should  be 

77  ~- 


610 


COLIC. 


applied  to  the  epigastrium,  provided  it  is  thought  inadvisable  to 
draw  blood  from  the  arm,  which  by  the  by  rarely  happens.  It  is 
worse  than  idle,  it  is  positively  cruel, to  urge  the  patient  to  swallow 
medicine  while  his  stomach  revolts  at  the  very  name  of  it.  The 
sickness  may  however  be  appeased  very  often  in  such  cases,  by 
the  following  mixture,  provided  there  is  no  suspicion  of  inflam- 
mation : — 


R.  Bis-carbon,  soda; 
Pulv.  g.  Arab. 
Ol.  menthx 
Sacch.  alb. 
Aq.  Seltzer  vel  font. 
M. 


3'iss. 

Take  Bi-carbonate  of 

5U- 

soda 

gut  iv. 

Powdered  gum 

§U- 

Arabic 

iv. 

Oil  of  mint 

Sugar 

Seltzer,  or  com- 

mon water 

Mix. 

1£  drachm. 

2  drachms. 
4  drops. 
2  drachms. 

4  ounces. 


Of  this  a  table-spoonful  may  be  taken  every  half  hour,  until 
better. 


3.  Blood-letting. 

2062.  Sometimes  in  these  cases,  nothing  but  the  abstraction 
of  blood  will  reconcile  the  stomach,  and  this  may  be  done  as 
above  directed,  by  either  the  lancet,  cups,  or  .leeches  ;  and  where 
there  is  a  necessity  for  this,  the  above  mixture  should  not  be  given 
until  this  has  been  done — then,  if  the  puking  persist,  it  may  be 
given.     Indeed,  the  loss  of  blood  becomes  indispensable,  when- 
ever the  constipation  is  obstinate,  the    stomach    irritable,  the 
tongue  red  and  dry,  and  the  urine  high-coloured  and  scanty ; 
for  inflammation  is  about  to  take  place,  or  has  already  done  so. 
After  these  remedies  have  been  faithfully  tried,  we  must  have 
recourse  to  the, 

4.   Warm  Bath. 

2063.  This  very  popular  remedy  is  often  very  much  abused, 
by  its  indiscriminate  employment.     The  warm  bath,  like  blis- 
tering, opium,  and  sweating,  has  its  point  of  efficacy.     For  if  it 
be  too  early  employed,  it  is  altogether  inadequate  to  the  end  in 
view;  and  if  left  too  late  it  is  sure  to  do  mischief,  by  calling  the 
blood  to  the  capillaries  of  the  surface,  at  a  time  the  internal  .and 
larger  vessels  cannot  spare  it.     The  proper  time  then,  is  imme- 
diately after  the  depletion  has  reduced  the  force  of  the  circula- 
tion, and  when  the  larger  internal  vessels  can  spare  some  blood 
to  the  capillaries  of  the  surface  without  injury.  The  water  should 
be  from  106°  to  110°  of  Fahrenheit ;  he  should  continue  in  the 
bath  until  he  complain  of  feeling  weak,  or  faintish;  and  should 


COLIC.  611 

he  experience  a  desire  to  discharge  from  his  bowels,  it  should 
be  permitted  even  in  the  bath,  rather  than  to  fail  to  have  it 
take  place. 

2064.  Unfortunately  for  the  interest  of  the  patient,  he  becomes 
unreasonably  impatient  of  relief,  or  his  friends  are  too  solicitous 
about  this  being  effected,  even  at  a  hazard;  opium  is  therefore 
proposed  ;  the  young  practitioner  too  readily  yields  to  the  sug- 
gestion, and  it  is  administered  at  a  time  when  it  serves  but  to 
increase  every  existing  evil.     This  medicine  therefore  can  only 
be  useful  when  exhibited  after  due  depletion,  and  when  the  exi- 
gency of  pain  demands  it.     It  should  therefore  never  be  given 
before  the  opiumpoint  arrives,  and  then,  if  given  by  the  mouth, 
it  should  be  in  combination  with  calomel,  in  the  proportion  of 
four  grains  of  the  latter  to  one  of  the  former,  if  the  dose  of  opium 
requires  repeating — if  it  do  not,  eight  or  ten  grains  of  calomel 
may  be  given.     But  laudanum  never  answers  so  well  in  these 
cases  as  when  given  in  injections.     A  tea-spoonful  to  a  gill  of 
warm  water  is  about  the  common  proportions. 

III.  Ileus,  or  Iliac  Passion. 

2065.  This  form  of  colic  is  the  most  dangerous,  but  fortunately 
at  the  same  time,  it  is  the  most  rare.     All  periods  of  life,  from 
the  infant  to  old  age,  may  be  liable  to  it.    Dr.  Good  defines  ileus 
as  follows :  "  griping  pain,  vomiting,  and  costiveness,  accompa- 
nied with  retraction  of  the  navel,  and  spasms  of  the  muscles  of 
the  abdomen."* 

2066.  In  investigating  the  symptoms  of  a  painful  disease  of 
the  bowels,  it  is  always  important  to  understand  the  condition 
of  the  alvine  discharges  previously  to  the  attack.     For  if  it  be 
ileus  we  have  to  contend  with,  it  will  almost  always  be  found 
that  there  has  been  a  constipation  of  some  standing,  though  the 
patient  may  declare,  that  he  has  had  a  discharge  daily;  in  this  we 
must  not  be  deceived  jf  the  patient  be ;  for  it  will  almost  always 
be  found  under  these  circumstances,  that  a  kind  of  tenesmus,  or 
a  very  trifling  evacuation  of  hard  faeces,  has  been  mistaken  for  a 
proper  discharge. 

2067.  The  pain  in  ileus  is  of  a  very  acute  kind,  especially 
near  the  umbilicus ;  it  however  suffers  occasional  abatement ; 
though  this  is  sure  to  be  followed  by  a  renewal  of  suffering. 
There  is  a  retraction   of  the  abdominal  muscles,  particularly 
during  the  painful  periods  of  the  disease.     The  feet  and  hands 
are  cold;  the  pulse  indicating  no  great  constitutional  sympathy; 
the  abdomen  is  not  sore  upon  pressure ;  nor  is  it  distended  by 

•  Vol.  I.  p.  121. 


612  COLIC.        * 

disengaged  flatus,  though  certain  inequalities,  and  occasionally 
hardnesses  may  be  discovered  beneath  the  abdominal  coverings. 
The  stomach  is  sometimes  affected  very  early  in.  this  disease;  in 
two  instances  we  have  witnessed,  vomiting  was  almost  the  initial 
symptom.  This  symptom  never  fails  to  increase,  if  the  consti- 
pation of  the  bowels  be  not  soon  relieved;  it  is  generally  at  first, 
bile,  and  the  common  secretions  of  the  stomach,  and  perhaps  of 
the  duodenum  ;  but  these  vomitings  may  be  accompanied  by  the 
stercoraceous  contents  of  the  large  intestines,  or  even  by  a  part 
of  the  injections  that  have  been  thrown  into  the  rectum;  thus 
proving  beyond  doubt,  that  the  valve  of  the  colon  has  been  forc- 
ed by  the  inverted  action  of  the  intestines.*  If  the  bowels  fail 
to  be  opened,  the  vomiting  becomes  almost  incessant,  and  the 
distress  of  the  patient  is  great  beyond  description;  for  the  little 
intervals  between  the  efforts  to  vomit,  are  filled  up  with  severe 
hiccoughings.  The  hands  and  extfemkies -are  cold  as  death,  and 
clammy  with  sweat  of  the  same  temperature;  the  pulse  is  thread- 
like and  fluttering,  or  perhaps  extinct.  About  this  time,  or  per- 
haps a  little  before  the  symptoms  become  so  dire,  the  bowels 
yield,  and  the  bed  is  deluged  with  fasces;  the  inexperienced 
friends  suppose  that  the  disease  has  relented  ;  and  that  hope  may 
now  be  entertained — but  unfortunately,  there  is  no  ground  for 
such  expectation,  for  the  speedy  death  of  the  patient  too  soon 
convinces  them  of  their  error. 

Causes. 

2068.  A  variety  of  causes  may  be  assigned  for  ileus ;  from  the 
simple  neglect  of  procuring  evacuations,  or  avoiding  constipa- 
tion, to  the  unnatural  and  complicated  habit  of  swallowing  knives, 
&c.  The  swallowing  of  the  stones  of  several  fruits,  as  cherries, 
plumbs,  &c.  under  the  vulgar  expectation,  that  they  are  more 
healthy  when  eaten  in  this  manner,  as  they  are  said  to  promote 
digestion.  An  inordinate  secretion  of  bile  of  an  unhealthy  qua- 
lity; acrid  substances  taken  into  the  stomach ;  drastic  cathartics; 
calculous  balls;  scybala;  violent  passions  or  emotions  of  the  mind  ; 
scirrhous  tumours,  &c.  &c.  Spasm  and  inflammation  of  the 
intestines,  have  also  given  rise  to  ileus,  in  a  manner  no  less  ex- 
traordinary than  incomprehensible.  Of  this  kind  are  those  cases 
related  by  M.  de  la  Peyrouse,t  and  Dr.  Gartshore.  J  In  these 

*  The  anatomical  arrangement  between  the  ilium  and  colon,  is  such,  as  to 
render  the  return  of  the  contents  of  the  colon  difficult,  but  by  no  means  im- 
possible, as  ileus,  and  the  forcing  of  fluids  from  the  rectum  into  the  bowels  by 
means  of  a  powerful  syringe  abundantly  prove. 

-j-  Memoires  de  1'Academie  Royale,  Vol.  XXIII. 

*  Med.  Obs.  and  Inq.  Vol.  IV. 


COLIC.  613 

cases  the  intestines  have  become  twisted  into  "  nooses  and  knots, 
in  which  the  portion  forming  the  encircling  cord  or  bridle  has 
been  drawn  so  tight  as  to  produce  strangulation,  and  render  gan- 
grene inevitable.  In  one  instance,  the  bridle  not  only  produced 
strangulation  and  gangrene,  but  cut  through  the  intestine  dfc  the 
opposite  side  to  the  mesentery,  making  an  opening  of  an  inch 
in  length."* 

2069.  Ileus  may  arise  from  intus-susception,  as  well  as  from 
spasm  or  inflammation;  the  mechanism  of  intus-susception  is  not 
however  very  well  understood,  though  its  explanation  is  attempt- 
ed by  Dr.  Good.     Neither  this  condition  of  the  bowel,  nor  in- 
flammation itself,  however,  are  essential  to  ileus,  if  we  regard 
the  testimony  of  Stoll,  Haller,  or  Morgagni.t  Indeed,  intus-sus- 
ception takes  place  very  frequently  in  children,  without  their 
deaths  having  been  preceded  by  ileus. 

Diagnosis. 

2070.  This  disease  cannot  be  well  mistaken;  its  characters 
are  too  strongly  pronounced  to  create  embarrassment  upon  this 
point.  The  retraction  of  the  abdominal  parietes;  the  relief  afford- 
ed by  pressure ;  the  moderate  excitement  of  the  system;  the  want 
of  distention  from  flatus,  and  the  absence  of  tympanitis,  and  her- 
nia distinguish  this  disease  from  peritonitis  and  enteritis. 

Prognosis. 

2071.  As  this  disease  is  one  of  great  violence,  as  well  as  of 
great  obstinacy;  and  as  the  parts  implicated  in  the  disease  are  of 
great  importance  to  life,  but  have  themselves  no  great  tenacity 
for  it,  the  result  of  any  given  case  must  necessarily  be  most  un- 
certain.    Indeed,  the  recoveries  from  ileus  are  declared  by  Dr. 
Gregory  to  be  very  few,  yet  the  disease  occurs  sufficiently  often 
to  make  us  ask  an  important  question,  "  is  ileus  necessarily  so 
fatal  a  disease,  as  is  declared  by  Dr.  Gregory,  as  to  justify  in  the 
majority  of  cases,  an  unfavourable  prognostic?"  We  think  not — 
we  shall  presently  advert  again  to  this  point. 

2072.  Yet  to  enable  the  inexperienced  practitioner  to  form  a 
judgment  upon  any  given  case,  we  will  state,  that  so  long  as  the ' 
bowels  do  not  yield,  notwithstanding  the  most  unwearied  appli- 
cation of  the  best  devised  means ;  and  the  puking  continues  of 
bile,  porraceous  matter,  or  above  all  faeces,  the  case  must  be 
looked  upon  as  extremely  menacing,  if  not  hopelessly  dangerous. 
If  with  these  there  be  hiccough,  suppression  of  urine,  cold  sweat, 

* 
•  Dr.  G.'s  case  just  alluded  to.  t  Good»  Vol.  L  p.  123. 


614  COLIC. 

fluttering  or  extinct  pulse,  the  patient  must  be  regarded  as  mori- 
bund, if  not  absolutely  in  articulo  mortis. 

2073.  On  the  other  hand,  if  the  bowels  have  been  made  to  de- 
ject their  contents ;  if  pain  moderate  in  proportion  to  the  alvine 
discharges ;  if  the  vomiting  diminish,  or  the  throwing  up  of  faeces 
cease ;  if  the  pulse  become  fuller,  softer,  and  slower ;  if  the  skin 
become  warm  and  moist,  and  there  is  a  plentiful  flow  of  urine, 
we  may  entertain  a  rational  expectation,  that  the  disease  will 
yield,  by  a  proper  perseverance  in  judicious  means.  The  patho- 
logy of  this  disease  will  be  readily  understood  from  what  has  al- 
ready been  said. 

Treatment. 

2074.  From  the  history  of  the  symptoms  of  this  disease,  it 
will  be  evident,  that  the  first  object  of  attention  is  to  remove  the 
obstruction  from  the  intestines ;  this  must  be  effected  by  indirect 
and  by  direct  means.  The  indirect  means,  are  bleeding  from  the 
arm,,  and  leeching  the  abdomen.    From  the  little  excitement  be- 
trayed in  the  beginning  of  this  complaint,  bleeding  is  too  often 
neglected,  until  it  becomes  almost  too  late  to  employ  it ;  and  this 
in  our  opinion  is  one  of  the  greatest  causes  of  the  fatality  of  the 
disease ;  for  we  are  far  from  agreeing  it  is  necessarily  so  fatal  as 
it  proves  to  be.  The  next  great  error  in  the  management  of  this 
disease,  is  the  ill-founded  and   injurious   distinction   between 
spasm  and  inflammation,  as  causes  of  it.     We  shall  not  stop  to 
inquire  into  the  pathological  differences  of  these  two  states;  for 
in  a  practical  point  of  view  in  this  instance,  it  is  of  no  importance 
whatever ;  since  one  will  quickly,  if  not  relieved,  be  converted 
into  the  other.  Suppose  it  to  be  spasm — is  any  antispasmodic  to 
be  compared  to  the  lancet,  under  these  circumstances?     Our  ex- 
perience declares  there  is  none.     If  there  be  inflammation,  will 
any  one  dispute  its  supremacy? 

2075.  Bleeding  should  therefore  be  immediately  had  recourse 
to ;  but  do  not  let  the  loss  of  ten  or  twelve  ounces  of  blood  be 
called  by  that  name,  unless  it  be  attended  while  flowing,  with  a 
disposition  to  syncope.     To  this  condition  of  the  system  must 
blood-letting  be  carried,  even  in  the  beginning,  as  a  general  rule; 
and  if  cathartics  have  failed,  or  enemata  have  been  unavailing, 
after  fair  trial,  it  becomes  absolutely  necessary.  However  hazard- 
ous or  rash  this  may  appear  to  the  inexperienced  or  timid  prac- 
titioner, we  can  vouch  both  for  its  safety  and  success,  in  a  num- 
ber of  instances,  where  the  cases  have  been  looked  upon  as 
desperate. 

2076.  Leeches  are  valuable  adjuvants  in  ileus;  they  ^should  be 
employed  however  after  general  bleeding,  unless  the  case  will 


COLIC.  615 

not  permit  its  employment  previously.  The  leeches  should  be 
placed  over  the  whole  abdomen,  and  in  such  number  as  to  se- 
cure the  effects  wished  for,  from  a  general  bleeding.  We  may 
now  employ  our  direct  means. 

2077.  After  these  evacuations  have  been  premised,  we  may 
then  advantageously  begin  with  our  purgatives.     The  choice  of 
these  is  of  the  utmost  consequence ;  for  the  improper  selection  of 
these  remedies,  constitutes  the  third  cause  of  the  danger  from 
ileus.     From  the  obstinacy  or  the  long  continuance  of  the  con- 
stipation, it  is  wrongly  imagined,  that  the  drastic  purgatives  are 
absolutely  required  to  overcome  it ;  than  which,  there  can  be  no 
greater  error. 

2078.  Castor  oil  is  the  best  possible  remedy  in  the  commence- 
ment of  the  disease,  and  before  puking  takes  place — but  after 
this,  it  cannot  be  urged  with  any  possible  advantage,  as  it  will  be 
rejected  as  fast  as  swallowed.     But  if  this  be  agreed  upon,  it 
should  be  given  by  the  table-spoonful  in  a  little  hot  coffee  every 
hour,  until  two  or  three  ounces  have  been  taken — it  must  now  be 
desisted  from,  and  recourse  had  to  enemata,  which  should  be 
made  to  act  by  their  bulk,  rather  than  by  their  stimulus — for  this 
purpose,  rich  flaxseed  tea,  and  molasses,  answers  exceedingly 
well,  strong  soap-suds  may  be  used  with  advantage. 

2079.  Should  these  be  rejected  without  bringing  with  them 
an  adequate  quantity  of  faeces,  or  be  returned  unaltered,  a  large 
quantity  should  be  forced  into  the  bowels,  by  throwing  up  syringe- 
ful  after  syringeful,  as  directed  by  De  Haen,  until  a  large  quan- 
tity be  thus  disposed  of.     Much  advantage  may  be  derived  from 
a  long  flexible  tube  being  passed  up  the  rectum,  as  it  will  better 
secure  the  introduction  of  the  contents  of  the  syringe.     Many 
stimulating  injections  have  been  advised  in  these  cases,  and  upon 
the  same  false  principle  as  the  active  purges  are  recommended — 
we  have  never  seen  them  successful,  though  we  have  known 
them  to  be  injurious.     For  their  action  and  effects  are  precisely 
like  those  of  the  drastic  cathartics — that  is,  they  increase  the  in- 
flammation or  irritation  of  the  mucous  membrane,  and  prevent 
the  effusion  of  serum;  while  the  mild  ones  abate  the  irritation, 
and  solicit  the  effusion. 

2080.  The  neutral  salts  are  also  valuable,  so  long  as  the  sto- 
mach will  retain  them — they  should  be  given  in  small,  but  often- 
repeated  doses,  until  so  much  has  been  taken,  as  to  lead  to  the 
conclusion  that  more  will  not  succeed.  It  is  in  this  state  of  things, 
that  bleeding  and  leeching  are  so  promptly  successful.  We  once 
attended  a  case  of  this  kind,  in  which  all  the  ordinary  means  had 
been  tried  without  benefit — that  is,  large  doses  of  calomel  had 
been  taken,  many  active  purgatives  had  been  swallowed,  and  she 
had  been  timidly  bled.     The  patient  had  not  had  a  passage  for 


616  COLIC. 

nearly  two  weeks ;  had  fed  plentifully,  and  moreover  was  seden- 
tary;  she  was  in  great  agony  ;  vomited  incessantly ;  and  was  ex- 
tremely feeble.  We  proposed  that  the  patient  should  be  placed 
upon  her  feet,  and  bled  in  this  position,  ad  deliquium  animi;  to 
this  the  attending  physician,  Dr.  Budd,  consented.  It  was  how- 
ever distinctly  stated  to  the  friends  of  the  patient,  that  there 
might  be  even  hazard  in  the  means  we  are  about  to  adopt,  but 
that  there  was  a  much  greater  chance  of  success;  but  in  all  events, 
that  the  case  was  one  of  great  danger,  and  if  not  relieved,  would 
certainly  prove  fatal.  Every  thing  was  left  with  us.  The  pa- 
tient was  taken  out  of  bed,  and  a  vein  was  opened  while  she  was 
standing;  a  large  orifice  was  made,  and  the  blood  flowed  pretty 
freely,  until  about  twenty  ounces  were  drawn ;  she  now  com- 
plained of  being  fainty ;  and  before  the  arm  could  be  tied  up, 
she  dropped  on  the  floor,  and  at  the  same  instant,  the  room  was 
nearly  deluged  with  faeces  and  urine.  She  had  no  further  pain, 
and  recovered  rapidly. 

2081.  When  the  stomach  will  retain  nothing,  calomel  is  the 
only  remedy  we  can  urge  upon  it.  This  should  be  tried  in  small 

.  doses;  as  it  is  the  only  proper  mode  to  exhibit  it.  It  is  a  mon- 
strous error,  in  our  opinion,  to  give  large  doses  of  this  medicine, 
when  a  cathartic  effect  alone  is  desired — for  certain  it  is,  that 
small  doses  are  vastly  more  sure  than  larger  doses.  In  these 
cases,  we  give  two  or  three  grains  every  hour,  in  a  little  dry 
sugar,*  until  twenty  or  thirty  grains  are  taken,  being  confident, 
that  beyond  this  quantity  in  twenty-four  hours  is  never  useful 
or  necessary.  After  this  quantity  has  been  given,  and  the  pa- 
tient has  been  freely  bled,  mild  enemata  can  now  be  employed 
with  advantage ;  for  we  are  pretty  certain  that  the  disease  will 
yield.  If  it  do  not,  the  bleeding  or  leeching  should  be  repeated, 
or  the  warm  bath,  as  directed,  (par.  2063,)  may  now  be  an  im- 
portant auxiliary.  We  have  seen  a  case,  which  we  shall  pre- 
sently relate,  in  which  the  croton  oil  was  advantageously  em- 
ployed. 

2082.  Where  the  pain  has  continued  to  be  great,  and  the  vo- 
miting persevering,  we  have  seen  the  spirit  of  turpentine,  in 
thirty  drop  doses  every  hour,  afford  much  relief.     We  have  ap- 
plied it,  we  think  with  advantage  to  the  abdomen,  and  found  it 
useful,  we  think,  in  the  enemata,  especially  after  an  extrication 
of  gas  has  taken  place,  which  sometimes  happens  when  the  dis- 
ease is  pretty  far  advanced.     We  have  never  blistered  in  these 
cases,  nor  have  we  ventured  upon  emetics,  as  advised  by  Stoll. 

*  Some  recommend  the  calomel  in  the  form  of  pills;  but  these  are  much 
more  liable  to  be  thrown  up,  than  in  the  way  we  have  mentioned;  as  this  be- 
comes spread  over  the  coats  of  the  stomach,  from  which  it  cannot  be  detached 
easily. 


COLIC.  617 

Besides  these  means,  many  irrational  'and  daring  practices  have 
been  occasionally  pursued  for  the  relief  of  this  disease ;  such  as 
dashing  the  legs  with  cold  water,  cold  bath,  drinking  large 
draughts  of  cold  water,  rolling  the  patient  in  the  snow,  &c.* 

2083.  Hitherto  we  have  said  nothing  of  opium;  a  drug  that  is 
so  often  successful  in  pain,  that  it  naturally  suggests  itself,  when- 
ever this  exists.  -Its  powers  however  are  very  decided  in  ileus, 
when  its  exhibition  is  well-timed  ;  but  unfortunately  it  is  used 
in  every  stage  of  the  disease,  without  the  slightest  reference  to 
the  state  of  the  system,  arid  this  forms  the  fourth  cause  of  dan- 
ger from  ileus.  It  answers  an  admirable  purpose  in  the  form  of 
enema,  (the  only  way,  by  the  by,  it  should  be  exhibited,)  after 
bleeding  has  been  duly  performed ;  and  the  enemata  have  pro- 

*  In  the  case  about  to  be  related,  there  is  much  interest  as  well  as  novelty — 
it  is  interesting1,  because  it  was  successful;,  and  it  is  novel,  as  we  believe  it  is 
the  first  instance  in  which  endermic  medication  has  been  resorted  to  in  ileus, 
for  such  the  disease  was  : — 

"Accumulation  of  Fiscal  Matter,  simulating  an  Internal  Strangulation, — A 
man  was  attacked  after  a  journey  with  symptoms  of  an  internal  strangulation; 
he  had  incessant  vomiting,  excessive  constipation;  the  abdomen  distended, 
and  very  painful  on  pressure;  vomiting  of  faecal  matters.  This  man  had  had  for 
a  long  time  a  reducible  hernia  which  he  had  recently  reduced;  but  he  affirmed 
that  it  offered  nothing  unusual,  and  that  he  had- applied  his  bandage  as  usual. 
Baths,  reiterated  bleedings,  diluents,  did  not  produce  any  relief.  In  consulta- 
tion the  question  was  agitated  whether  an  operation  should  not  be  performed, 
and  whether  there  was  not  an  internal  strangulation.  The  majority,  however, 
were  opposed  to  the  operation.  The  patient  continued  in  this  condition  until 
the  fifteenth  day,  faecal  matters  being  thrown  up,  and  his  strength  declined. 
At  this  time  a  celebrated  surgeon  being  called  in,  proposed  an  operation, 
thinking  that  it  was  necessary  to  operate  even  in  the  absence  of  any  evident 
sign  of  a  strangulated  tumour,  either  in  the  inguinal  canal,  in  the  abdomen,  or 
in  the  neighbourhood  of  the  ring.  The  operation  was  determined  upon — but 
as  M.  Sanson  was  about  commencing,  perceiving  no  tumour,  nor  pain,  nor 
tension  of  any  kind  above  the  ring,  nor  in  the  inguinal  canal,  nor  deeply  in  the 
vicinity,  and  remarking  that  the  point  of  the  abdomen  corresponding  to  the 
hernia  was  the  only  one  which  was  neither  painful  nor  tense,  he  examined  the 
abdomen  anew  with  great  care,  and  discovered  on  the  left  side,  deep-seated 
and  obscure,  a  long  tumour,  which  seemed  to  him  to  be  the  colon  filled  with 
indurated  faecal  matters.  He  introduced  the  finger  into  the  rectum  as  deeply 
as  possible;  he  experienced 'great  difficulty  in  introducing  it,  so  much  was  it 
contracted.  He  then  endeavoured  to  introduce  a  gum  elastic  sound,  but  it 
.  would  not  enter  far,,  so  strong  was  the  constriction  of  the  digestive  tube.  Many 
enemata  of  olive  oil  were  injected  with  force;  at  first  they  produced  no  effect, 
but  on  continuing  them  they  brought  away  some  soft  yellow  matters;  they 
were  continued  without  interruption.  M.  Sanson  then  determined  to  adminis- 
ter a  purgative,  but  it  was  impossible  to  .give  it  by  the  mouth,  the  vomiting  be- 
ing continued,  and  the  patient  not  being  able  to  retain  even  a  cup  of  water.  A 
small  blister  was  applied  to  the  thigh,  and  after  removing  the  epidermis,  a  drop 
of  oil  of  croton  tiglium  was  placed  on  the  cutis;  an  abundant  evacuation  result- 
ed. The  vomiting  ceased;  the  patient  evacuated  in  three  or  four  days,  many 
pounds  of  soft,  fellow,  faecal  matters.  All  the  symptoms  evidently  depended 
upon  this  accumulation  of  fxcal  matters  in  the  digestive  tube." — Jlmer.  Journ. 
of  Med.  Scien.  for  Feb.  1831,  p.  518,  from  Journal  de  Mededne  Prat.  July,  1830. 

78 


618  COLIC. 

duced  an  irritable  condition  of  the  rectum;  and  when  it  becomes 
important  to  give  to  the  remedies  exhibited  by  the  mouth,  time 
to  operate  Then  a  wine-glassful  of  rich  flaxseed  tea,  and  a  tea- 
spoonful  of  laudanum,  thrown  up  the  rectum,  will  almost  always 
secure  some  repose  to  the  patient.  Should  the  first  enema  be 
rejected,  a  second  or  a  third  should  be  given,  at  short  intervals — 
or  a  suppository  of  six  grains  of  opium  may  be  introduced  be- 
yond the  sphincter  ani. 

2084.  The  following  case,  in  our  view,  has  much  interest ; 
we  shall  therefore  take  the  liberty  to  relate  it  in  detail.   Septem- 
ber 13th,  1S24. — We  were  called  this  morning  at  five  o'clock, 
to  Mrs.  M.  whom  we  found  labouring  under  severe  pain  in  the 
umbilical  region,  with  an  incessant  vomiting  of  faecal  matter ; 
her  skin  cold,  shrunk,  and  wet  with  perspiration;  the  pulse  tense, 
small,  and  frequent— bowels  much  constipated.     She  had  taken 
a  number  of  purgative  medicines  before  we  saw  her,  and  had  re- 
ceived a  number  of  injections,  without  benefit.     The  stomach 
would  retain  nothing  a  single  moment,  and  the  injections  return- 
ed as  soon  as  given.     To  be  bled  sitting  up,  until  she  felt  faint; 
a  drop  of  croton  oil  every  hour,  until  it  operate;  warm  water  and 
molasses  to  be  thrown  up  the  rectum,  syringeful  after  syringeful, 
until  the  bowels  were  filled  with  it 

2085.  1 1  o'clock,  A.  M.    We  saw  our  patient  six  hours  after 
the  first  visit    We  found  her  much  relieved ;  lost  about  twenty 
ounces  of  blood  before  she  became  faint — blood  very  sizy — four 
drops  of  croton  oil  had  been  given,  which  sat  well  upon  the  sto- 
mach;  she  received  six  large  syringes  of  molasses  and  water. 
The  bowels  yielded  almost  immediately  after  the  bleeding,  and 
the  injections — she  had  large  bilious  stools  of  a  yellow  colour, 
but  without  smell.     An  injection  of  a  gill  of  water  and  a  tea- 
spoonful  of  laudanum,  and  the  loss  of  more  blood,  in  case  of  a  re- 
turn of  pain — two  drops  of  croton  oil  immediately. 

2056.  5  o'clock,  P.  M.    Free  from  pain ;  no  vomiting  since 
the  morning — the  croton  oil  procured  several  more  loose  stools — 
the  laudanum  was  not  used,  nor  the  bleeding  resorted  to,  as  she 
continued  to  be  free  from  pain — a  wine-glassful  of  weak  chicken 
water,  every  hour  or  two ;  toast  tea  in  small  quantities  for  drink. 

2057.  14M. — 9  o'clock,  A.  M.    Complains  of  a  little  pain 
around  the  navel — pulse  a  little  accelerated,  with  some  warmth 
of  skin,  owing  njost  probably  to  the  use  of  the  chicken  water. 
An  ounce  of  ol.  ricini.     6  o'clock,  P.  M.  Oil  operated  pretty 
freely  ;  free  from  pain  and  fever— diet,  a  little  thin  sago  or  ta- 
pioca—drink, as  before. 

2058.  15/A.  Found  the  patient  sitting  up  in  bed,  though  she 
had  passed  rather  an  unquiet  night,  owing  to  the  operation  of  her 
medicine.     In  these  discharges  wras  voided  a  ball  of  the  size  of  a 


COLIC.  619 

pullet's  egg,  and  of  an  egg-like  shape,  with  many  small  stones, 
of  which  we  received  seven,  they  not  having  preserved  the  rest. 
They  were  of  irregular  shapes,  smooth,  pretty  highly  polished, 
and  of  a  fine  hrown  colour,  interspersed  with  bright  yellow 
-  streaks — the  brown  tone,  was  precisely  the  same  as  the  tamarind 
seed ;  the  large  mass,  was  evidently  formed  by  aggregation  or 
deposition,  as  the  different  strata  of  which  it  was  composed, 
could  be  distinctly  seen.  They  were  deposited  in  the  museum 
of  our  medical  college. 

2089.  16th.  Free  from  complaint ;  passed  another  small  stone. 
nth.  Perfectly  well. 

Observations. 

2090.  The  patient  was  attacked  on  Easter  Sunday,  with  an 
intermittent,  which  lasted  a  week — during  the  greater  part  of 
the  summer,  her  bowels  were  alternately  constipated,  and  relax- 
ed, with  a  pretty  constant  pain  about  the  navel.     Regular  in  her 
menses ;  forty-two  years  of  age,  and  the  mother  of  nine  children. 

2091.  On  the  9jth  of  September,  1824,  she  was  attacked  with 
vomiting,  and  pain  in  the  abdomen ;  bowels  very  costive ;  she 
took  a  large  dose  of  aloes,  but  it  did  not  operate.    She  remained 
in  this  situation  until  the  14th,  when  we  were  called,  and  found 
her  in  the  state  above  described. 

2092.  This  case,  as  well  as  the  one  mentioned  before,  demon- 
strate clearly  the  importance  of  bleeding  ad  deliquium  animi, 
even  after  the  formidable  symptom  of  throwing  up  the  faeces  had 
taken  place ;  we  have  known  but  one  case  of  fatal  ileus  for  many 
years,  and  that  we  did  not  see  till  within  three  hours  of  death. 

IV.  Colica  Picfonum,  or  Colic  from  Lead. 

2093.  This  colic  is  peculiar,  because  it  has  necessarily  for  its 
cause  the  application  of  lead.  This  is  determined  by  the  liability 
of  those  who  work  in  the  preparations  of  this  metal,  or  are  .con- 
cerned in  its  various  preparations.     It  may  however  take  place 
in  those  who  have  no  direct  concern,  either  in  its  manufacture, 
or  in  its  use — thus  this  metal  may  be  conveyed  into  the  system, 
or  be  made  to  act  upon  it,  in  various  ways.     Its  fumes  may  be 
breathed,  as  those  who  are  in  the  environs  of  smelting  furnaces, 
have  frequently  experienced ;  indeed,  in  such  situations,  animals 
are  said  to  have  suffered  from  the  same  cause ;  and  we  know  it 
has  been  repeatedly  produced  by  sleeping  in  a  newly-painted 
room,  or  from  even  remaining  a  long  time  in  an  atmosphere  load- 
ed with  emanations  from  white  lead  paint.     It  may,  and  it  very 
often  has  been  conveyed  immediately  to  the  stomach,  by  wines 


630  COLIC. 

which  have  had  their  acidity  corrected  by  the  sugar  of  lead,  or 
by  litharge.  *  Water  which  has  stood  a  long  time  in  a  leaden  ves- 
sel, or  has  been  conducted  by  leaden  pipes,  has  been  accused  of 
producing  this  colic ;  of  this  however  considerable  doubt  may  be 
justly  entertained,  as  the  experiments  and  observations  of  Dr. 
Percival  appear  to  be  conclusive,  though  the  contrary  opinion  is 
maintained  by  Pariset  and  others. t 

2094.  Lead  in  its  metallic  form  does  not  appear  to  have  any 
unfavourable  influence  upon  the  system,  either  externally  applied 
or  internally  deposited — for  it  has  long  been  the  means  of  making 
pressure  externally,  in  the  umbilical  hernia;  and  balls  have  been 
retained  for  many  years  in  various  parts  of  the  body,  without 
being  followed  by  the  slightest  injury.  But  when  in  a  state  of 
oxyde,  or  in  form  of  a  salt,  it  has  when  applied  been  followed 
by  paralysis,  or  other  inconvenience,  (par.  890,)  and  Sir  Astley 
Cooper  witnessed  the  same  misfortune  follow  the  use  of  a  colly- 
rium,  in  which  lead  entered.  It  may  also  be  conveyed  to  the 
stomach  by  the  saliva,  or  more  abundantly  swallowed  by  eating 


•  "  In  a  late  sitting  of  the  Westminster  Medical  Society,-  Dr.  Thompson  stated, 
from  a  number  of  experiments  and  observations,  that  none  of  the  salts  of  lead, 
with  the  exception  of  the  carbonate,  are  poisonous.  Where  mischief  has  re- 
sulted from  the  taking1  of  acetate  and  subacetate  of  lead,  he  believed  the  cause 
was  the  conversion  of  these  into  carbonate." — Medico-Chirur.  Review  for  Feb. 
1830,  p.  491. 

•j-  Dr.  Christison  has  proved,  that  the 'tarnish  the  clean  surface  of  lead  re- 
ceives, is  not  from  oxidation,  but  by  a  thin  layer  of  the  carbonate  of  lead,  form- 
ing. The  formation  of  this  crust  is  aided  by  moisture,  and  probably  by  the 
presence  of  extra-carbonic  acid  in  the  air.  Dr.  Lambe  says  that  most  if  not  all 
spring  water  possess  the  power  of  acting  on  lead,  owing  to  the  presence  of 
some  saline  ingredients.  Guyton-Morveau  proves  that  distilled  water  acts  ra- 
pidly on  lead,  by  converting  it  into  a  hydrated  oxide.  And  Dr.  Thompson  of 
Glasgow  maintains  that  the  lead  in  water  is  only  suspended,  and  is  not  held  in 
solution,  and  thinks  that  the  quantity  in  water  passing  through  leaden  pipes, 
is  too  small  to  be  injurious. 

Dr.  Christison  found  that  distilled  water  deprived  of  its  gases,  and  protected 
from  the  air,  had  no  action  on  lead.  But  with  its  customary  gases,  a  freshly 
polished  surface  of  lead  exposed  to  it  becomes  quickly  tarnished  and  white. 
This  white  crust  is  a  carbonate.  Rain  or  snow  water,  before  it  touches  the  earth 
is  nearly  as  pure  as  distilled  water,  and  acts  with  nearly  the  same  rapidity;  but 
when  collected  in  a  city,  and  contaminated  with  certain  substances,  its  activity 
is  much  diminished — owing  to  certain  substances  held  in  solution  by  the  water, 
as  perhaps  alt  the  neutral  salts,  as  the  sulphates,  nitrates,  acetates,  tartrates, 
arseniates,  &c.  having  the  power  to  destroy  the  solvent  power  of  water-.  These 
facts  are  curious  and  interesting.  "  Most  spring  waters,  unlike  rain  or  snow 
water,  have  little  or  no  action  on  lead,  because  they  generally  contain  a  con- 
siderable proportion  of  muriates  and  sulphates."  And  in  consequence  Dr. 
Johnson  observes,  "the  water  of  Edinburgh  appears  to  be  nearly  destitute  of 
r.U  action  on  lead; — and  we  think  the  good  citizens  of  London  need  not  be 
much  afraid  of  the  painter's  colic  while  they  are  supplied  with  water  from  the 
Thames,  or  even  the  new  river.  If  the  purity  of  water  be  a  dangerous  property, 
the  metropolis  is  as  secure  as  if  they  drank  nothing  but  nectar." — Ibid.  p.  493. 


COLIC.  621 

with  unwashed  hands,  as  Good  informs  us  lie  prevented  it  in  a 
painter,  by  advising  the  careful  washing  of  his  hands. 

2095.  When  lead  is  introduced  in  solution  into  the  stomach, 
its  effects  are  more  obvious  upon  the  digestive  organs  than  upon 
the  nervous  system.     Yet  we  know  from  experience,  unless  in- 
fluenced by  idiosyncrasy,  the  acetate  of  lead  may  be  taken  for  a 
considerable  time,  without  the  slightest  inconvenience ;  and  it  is 
applied  daily  externally  to  large  and  oftentimes  to  very  irritable 
surfaces,  without  any  evil  consequence  following.     It  is  never- 
theless, a  metal  that  should  not  be  trusted  too  far,  when  it  can  be 
avoided,  as  it  produces  consequences  every  way  troublesome,  as 
well  as  difficult  to  remove. 

2096.  When  about  to  produce  mischief  in  the  alimentary  canal, 
as  colic,  we  find  eostiveness  of  an  obstinate  kind  induced ;  ren- 
dering the  fasces  at  the  same  time  hard,  and  having  them  formed 
into  little  balls,  resembling  those  evacuated  by  sheep  or  goats. 
The  mouth  is  bitter,  and  the  tongue  foul  or  even  dry.     A  sensa- 
tion of  weight  or  dragging  is  felt  about  the  epigastrium;  nausea, 
and  sometimes  painful  and  obstinate  vomiting.     The  belly  now 
becomes  sore,  but  not  always  to  the  touch;  borborygmi  are  al- 
most constantly  heard ;  the  whole  abdomen,  the  hips,  the  loins, 
the  umbilicus,  and  the  stomach,  become  in  turn  the  seat  of  pain, 
which  seems  to  be  relieved  by  pressure  sometimes,  but  aug- 
mented at  others.     A  sensation  like  globus  hystericus  is  felt  in 
the  throat ;  acid,  or  acrid  eructations  ;  hiccough ;  the  abdominal 
parietes  are  hard  and  soft  in  places ;  tumours  of  unequal  size  may 
be  discovered  below  them,  which  often  change  their  place.  Pain- 
ful tenesmus,  extreme  agony,  and  loud  and  fearful  cries  now  fol- 
low, and  continue  with  more  or  less  force,  until  the  paroxysm  is 
removed  by  proper  applications.     This  however  is  of  uncertain 
duration,  as  remedies  may  be  more  or  less  judiciously  selected, 
or  as  they  may  be  more  or  less  efficient.  Pain  more  or  less  acute 
has  continued  for  years  without  much  aggravation  or  diminu- 
tion, and  seems  to  afflict  more  by  its  obstinac}7,  than  by  its  se- 
verity.    In  these  chronic  cases,  the  belly  becomes  contracted  at 
one  time  and  relaxed  at  others,  -but  always  experiencing  more  OP 
less  inconvenience. 

2097.  Fever  rarely  attends  this  disease  in  the  beginning, 
though  the  circulating  system  is  singularly  and  decidedly  affect- 
ed— the  pulse  is  uniformly  of  an  unnatural  hardness ;  nor  is  this 
an  evanescent  condition,  or  easily  conquered,  as.it  persists  until 
every  other  symptom  disappears.  The  breathing  is  also  affected, 
in  consequence  of  a  convulsive  motion  of  the  diaphragm  and  ab- 
dominal muscles.     The  brain  does  not  appear  to  be  much  or 
acutely  affected,  though  head-ache,  giddiness,  loss  of  memory, 


622  COLIC. 

and  anxiety  are  observed — we  have  seen  delirium  but  once  in 
this  complaint. 

2098.  The  limbs  are  affected  oftentimes  severely  in  this  dis- 
ease; not  so  much  during  the  paroxysm,  as  after  it  has  passed. 
In  protracted  cases,  much  inconvenience  is  experienced  in  all 
the  limbs,  as  pains  resembling  rheumatism,  or  inability  to  move, 
bordering  on  paralysis,  are  almost  sure  to  follow. 

Diagnostic, 

2099.  This  disease  may  be  confounded  with  enteritis,  when  it 
first  invades  the  system,  especially  in  young  subjects;  but  atten- 
tion to  the  occupation,  or  the  probability  of  exposure  to  the  in- 
fluence of  lead,  will  lessen  the  difficulty  of  distinguishing  these 
affections  from  each  other.     The  pain  in  this  colic,  is  more  con- 
fined to  the  umbilicus,  and  diffuses  itself  to  the  neighbouring 
parts ;  the  patient  is  also  able  to  bear  pressure ;  indeed,  he  often 
presses  himself  against  the  edge  of  a  table  with  a  view  to  relieve 
himself;  the  absence  of  febrile  motion  for  the  most  part;  and  the 
almost  constant  state  of  retraction  of  the  abdominal  muscles, 
strongly  mark  this  disease. 

Prognostic. 

3000.  If  much  puking,  fever,  heat  of  skin,  aceelerated  pulse, 
little  or  no  urine,  and  that  high-coloured  and  offensive,  obstinate 
constipation,  swelling  with  tenderness  of  the  belly,  cramps  in 
the  legs,  and  hiccough  attend,  the  augury  must  necessarily  be 
bad.     But  if  the  contrary  of  these  symptoms  obtain ;  especially 
if  the  stomach  is  quieted,  the  bowels  yield  readily,  the  skin  be- 
come soft  and  disposed  to  moisture,  and  the  urine  be  plentifully 
secreted,  the  disease  will  almost  always  be  obedient  to  remedies, 
and  proper  treatment. 

Pathological  Appearances. 

3001.  Never  having  had  an  opportunity  of  examining  a  body 
destroyed  by  colica  pictonum,  and  feeling  it  highly  important 
to  its  treatment  that  its  pathology  should  be  understood,  we 
have  selected  Pariset's  account  of  the  appearances  on  dissection 
of  patients  who  had  died  of  this  disease.* 

3002.  "  On  opening  the  dead  bodies,  the  intestines,  but  espe- 
cially the  colon,  are  found  contracted  in  several  portions  of  their 

*  See  Diet,  des  Sciences  Mcd.  Art.  Colique. 


COLIC.  623 

length,  and  filled  in  the  intervals  of  these  narrowings,  with  a 
dry,  hard  matter.  On  the  stomach  we  may  observe  red  or  brown 
spots,  and  the  bowels  have  the  appearance  of  being  braised. 
The  bladder  often  betrays  marks  of  great  irritation,  especially 
near  its  neck;  the  mesenteric  vessels,  and  the  whole  system  of 
the  vena  porta,  are  filled  with  blood." 

3003.  Lobstein  is  of  opinion  that  a  pathological  condition  of 
the  sympathetic  nerve  is  the  cause  of  colica  pictonum.     Pariset 
takes  no  notice  of  the  nervous  system  in  his  account  of  this  dis- 
ease.    This  disease  certainly  presents  some  remarkable  pheno- 
mena, as  globus  hystericus,  paralysis,  &c.  which  would  be  of 
difficult  explanation,  from  inflammation  of  the  common  tissues 
of  the  stomach  and  intestines. 

Treatment. 

3004.  Though  we  do  not  in  general  discover  in  colica  picto- 
num a  well-marked,  or  distinctly-formed,  pyrexia,  it  is  never- 
theless certain,  that  in  this  disease  the  arterial  system  is  mate- 
rially affected,  together  with  local  inflammation,  as  a  tense  and 
vibrating  pulse,  (par.  2097,)  and  as  post  mortem  examinations 
declare.     It  must  therefore  be  certain,  that  the  proximate  cause 
of  this  disease  is  inflammation  produced  by  the  action  of  lead,  in 
someone  or  more  of  the  intestines,  and  occasionally  the  stomach 
itself.     It  has  been  owing  to  the  absence  of  the  signs  of  phleg- 
masia,  as  indicated  by  the  condition  of  the  sanguiferous  system 
on  the  one  hand,  and  the  presence  of  violent  pain,  especially 
when  it  assumes  an  alternate,  or  spasmodic  form,  on  the  other, 
that  the  proximate  cause  of  colica  pictonum  has  been  looked  upon 
as  a  derangement  of  the  nervous  system.     But  this  is  a  very 
partial,  and  we  may  add,  imperfect  view,  of  what,  on  the  one 
hand,  may  constitute  phlegmasia,  and  on  the  other,  neurosis. 

3005.  For  modern  pathologistshave  mostsatisfactorily  proved, 
that  inflammation,  and  this  to  a  very  considerable  extent,  may 
exist  without  the  ordinary  signs  of  this  condition,  (such  as  an  ac- 
celerated pulse,  heat  of  skin,  or  thirst;)  and  on  the  contrary,  that 
the  latter  signs  do  not  prove  to  a  certainty,  the  former,  or  the 
inflamed  state  of  a  part;  and  consequently,  that  pain,  on  the  one 
hand,  accompanied  by  heat,  and  an  increased  arterial  action  in 
the  part,  as  in  certain  of  the  neuralgias,  do  not  absolutely  prove 
the  presence  of  inflammation,  so  on  the  other,  the  absence  of 
these  signs  do  not  prove  its  non-existence. 

3006.  It  appears,  however,  every  way  certain,  that  neither  of 
these  conditions  continue  long  idiopathically,  in  either  of  the 
systems  just  mentioned,  (par.  3005,)  for  they  will  soon  mutually 
involve  each  other;  and  theoretically,  perhaps,  it  might  appear 


624  COLIC. 

a  matter  of  indifference,  in  which  of  these  systems  the  irritation 
commence,  if  this  would  be  the  certain  result ;  but  it  may  be 
highly  important  in  a  therapeutical  point  of  view.  For  if  the  pri- 
mitive impression  be  upon  the  nervous  system,  it  is  every  way 
certain,  it  will  not  be  long  confined  to  it ;  as  it  will  pretty  quick- 
ly manifest  its  influence  upon  the  circulating  system.  Or,  if  we 
suppose  the  irritation  to  be  originally  in  the  sanguineous,  it  will 
be  confined  to  it  but  a  short  time  before  the  influence  of  the  ir- 
ritation will  be  felt  by  the  nervous  system. 

3007.  If  it  be  certain  then,  as  declared  by  some,  that  the  ac- 
tion of  lead  is  always  immediately  upon  the  nervous  system,  it 
is  nevertheless  no  less  certain,  that  the  circulating  system  will 
be  quickly  implicated.     In  a  limited,  or  a  purely  hypothetical 
view,  it  might  be  insisted,  that  our  remedies  should  be  address- 
ed to  the  nervous  system  in  attempting  the  cure  of  colica  picto- 
num,  as  there  must  be  a  period  under  this  consideration  of  the 
subject,  that  it  would  be  idle,  if  not  injurious,  if  it  were  treated 
as  a  disease  of  the  sanguiferous  system.     We  admit  this  to  be 
theoretically  correct;  but  if  acted  upon,  it  would  be  highly  mis- 
chievous in  very  many  instances,  as  this  state  of  things  is  not 
only,  (most  probably,)  very  evanescent,  but  so  extremely  ob- 
scure, that  we  should  find  it  difficult  to  determine  its  pure  and 
uncomplicated  existence,  or  when  this  was  about  to  cease. 

3008.  For  these  reasons  we  must  regard  a  phlogosed  condi- 
tion of  the  intestines  to  be  the  most  probable,  as  well  as  by  far 
the  most  common,  in  colica  pictonum.    So  far,  we  have  seen  no- 
thing in  the  acute  form  of  this  disease,  to  lead  us  to  suppose,  that 
the  irritation,  or  influence  of  the  remote  cause  of  this  disease,  is 
confined,  beyond  an  imaginary  period,  to  the  nervous  system ; 
and  consequently,  to  act  upon  the  presumption,  that  it  is  con- 
stantly so,  would  but  ill  comport  with  what  we  learn  from  the 
examination  of  the  dead  body.   (par.  3002.) 

3009.  Our  own  experience  therefore  is  so  entirely  in  favour 
of  the  antiphlogistic  plan  of  treatment;  and  our  success  has  been 
hitherto  so  uniform,  that  we  should  find  it  difficult  to  lay  down 
a  plan  of  treatment  essentially  different  from  that  suggested  for 
ileus.   It  may  however  be  proper,  or  perhaps  useful,  to  say,  that 
in  a  recent  and  obstinate  case,  that  after  pretty  extensive  bleed- 
ings, general,  as  well  as  local;  the  various  mild  cathartics,  and 
the  repeated  employment  of  the  warm  bath,  we  found  equal 
parts  of  castor  oil,  and  spirit  of  turpentine,  in  half  ounce  doses, 
once  in  two  hours,  to  open  the  bowels  with  great  certainty.   We 
are  disposed  to  believe,  that  these  evacuations  were  the  effect  of 
this. combination,  and  not  a  coincidence;  as  this  patient  had  a 
severe  relapse  about  a  week  after  we  had  taken  our  leave  of 
him;  for  which  he  had  again  to  undergo  a  discipline  pretty  si- 


COLIC.  625 

milar  to  the  first;  and  he  was  again  operated  on  by  the  castor  oil 
and  the  turpentine. 

3010.  But  notwithstanding  our  conviction,  that  the  disease  is 
essentially  an  inflammation  of  the  intestines  under  some  parti- 
cular modifications  of  the,  (perhaps,)  nervous  system,  we  are  ne- 
vertheless obliged,  as  a  matter  of  common  honesty,  to  rely  upon 
the  truth  of  the  treatment  about  to  be  mentioned,  but  which 
puts  all  theory,  or  pathology,  to  defiance — this  is,  the  almost 
exclusive  treatment  of  this  disease  by  large  and  repeated  doses 
of  alum.     For  the  better  understanding  of  the  treatment  of  this 
disease  by  this  method,  we  will  transcribe  a  case,  with  the  rou- 
tine of  practice  that  was  pursued  in  it.     It  is  taken  from  the 
"Archives  Generales  de  Medicine,  torn,  xviii.  an.  1828." 

3011.  It  is  declared  in  the  title  to  this  paper,  that  the  cases 
were  collected  under  the  eyes  of  M.  Kapeler,  physician-in-chief 
to  the  Hospital  of  St.  Anthony,  by  M.  D.  Montanceix.     We 
have  taken  the  case  at  random ;  only  taking  care  to  have  one  of 
the  several,  that  contrasts  the  practice  of  "  de  1'Hospital  Saint 
Antoine,"  with  "de  la  Charite." 

3012.  "CASE   III. — J.   Maiseau,  of  a  strong  constitution, 
bilious  temperament,  aged  forty-years,  a  cooper,  was  brought 
into  the  hospital  of  St.  Anthony,  on  the  27th  February,  in  a 
condition  that  was  at  first  mistaken  for  intoxication;  this  was 
followed  at  intervals  by  a  furious  madness,  that  disposed  the  pa- 
tient to  attack  every  body  around  him.  He  thought  every  body 
had  a  design  on  his  life,  and  upon  the  slightest  noise  would  put 
himself  on  the  defensive.    If  we  attempted  to  press  upon  his  ab- 
domen, he  would  get  into  a  rage,  and  threaten  severely.     He 
however  would  appear  comforted  by  the  pressure.     The  pulse 
was  extremely  slow.    Not  knowing  any  thing  of  this  man's  his- 
tory, we  could  not  account  for  his  conduct;  his  papers  however 
were  now  brought  to  us.     We  found  by  these  that  Maiseau  had 
been  several  times  treated  for  colica  pictonum.  One  of  these  pa- 
pers declared  the  patient  had  left  the  "Charite"  on  llth  of  Feb- 
ruary, cured  of  a  metallic  colic,  after  a  stay  of  three  months  in 
that  institution.     From  this  testimony  we  did  not  hesitate  to 
give  him  a  drachm  of  the  sulphate  of  alumine,  and  a  purgative 
glyster.     Three  hours  after  this  he  had  a  tranquil  interval,  and 
he  passed  the  night  pretty  quietly.     No  stool. 

301S.  "28th.  More  quiet,  but  his  mind  constantly  wrong; 
pulse  very  slow ;  the  abdomen  painful ;  the  patient  tossing  his 
head  continually  in  all  directions;  his  eyes  staring;  tongue  dry 
and  red;  (two  drachms  of  alum;  a  purgative  enema  every  two 
hours ;  flaxseed  tea.)  At  four  o'clock  in  the  afternoon  the  pa- 
tient recovered  his  senses;  he  answered  questions  properly,  and 
had  no  recollection  of  what  had  passed;  colic  constant;  he  lost 

79 


626  CYSTITIS 

his  sight,  (amaurosis;)  he  trembled  in  all  his  limbs.  No  stool; 
(two  drachms  of  alum  ;  two  purgative  injections.)  29th.  More 
pain,  and  trembling;  return  of  appetite;  loss  of  sight  continues. 
Four  stools  during  the  night;  (prescription  the  same.  )  1st.  March. 
In  same  condition..  2d.  Begins  to  distinguish  objects;  (prescrip- 
tion the  same.)  Nourishment.  15th.  Recovered  his  sight  en- 
tirely, from  the  3d  to  the  12th;  he  took  every  day  a  drachm  of 
alum.  Several  boils  appeared  successively  on  his  body,  and  on 
the  thighs.  He  left  the  hospital  perfectly  well,  after  having  been 
there  forty-five  days." 

3014.  Alum  is  by  no  means  a  new  remedy  in  colica  picto- 
num;  it  was  first  proposed,  we  believe,  by  Dr.  Grashiusas  a  spe- 
cific in  this  disease.  M.  Gendrin  says  that  the  sulphuric  acid 
in  the  dose  (quantity?)  of  a  drachm  or  drachm  and  a  half 
mixed  with  three  or  four  pints  of  water,  is  equally  efficacious  and 
perhaps  more  prompt,  than  the  alum.  —  Trans.  Med.  January, 
1S32.  And  as  a  preservative  against  attacks  of  this  colic,  he 
recommends  — 

B.  Sulphuric  acid  3j- 

Water   - 


A  glassful  to  be  taken  daily,  sweetened  with  the  syrup  of  gum. 

SECT.  VII.  —  CYSTITIS. 
Jicute  Cystitis. 

3015.  Men  rather  advanced  in  life,  if  we  can  rely  upon  our 
experience,   are  more  liable  to  cystitis,   than  the  young  and 
healthy.     We  have  seen  two  attacks  of  this  disease  where  the 
subjects  were  each  beyond  their  eightieth  year.    In  females  it  is 
comparatively  a  rare  disease. 

Symptoms. 

3016,  Lancinating  pains  are  felt  in  the  region  of  the  bladder, 
accompanied  by  a  constant  burning  sensation.     There  is  also  a 
frequent  desire  to  pass  water  ;  which,  when  the  effort  is  made, 
eventuates  in  a  sparing  dribbling,  that  neither  abates  the  irrita- 
tion, nor  affords  relief.      Sometimes  there  is  an  entire  retention 
of  urine.     When  urine  is  passed,  it  is  generally  high-coloured, 
or  even  tinged  by  blood.  In  some  instances,  there  is  a  continued 
slillicidium  of  urine;  especially,  if  the  bladder  be  full.    A  con- 
stant aching  pain  is  felt  in  the  perineum,  which  is  increased  by 
even  moderate  pressure  ;  when  this  is  intense,  the  rectum  be- 
comes involved  by  sympathy;  and  a  kind  of  nisus  or  tenesmus. 


CYSTITIS.  627 

is  sometimes  excited  ;  and,  if  the  effort  be  obeyed,  it  greatly 
augments  the  painful  sensation  at  the  neck  of  the  bladder.  If  the 
part  immediately  above  the  pubes  be  pressed,  it  gives  considera- 
ble pain ;  and  by  a  careful  examination  of  this  part,  we  may  in, 
some  instances  detect  the  distended,  and  irritated  bladder.  The 
testicles  also  are  sometimes  involved,  and  become  very  painful, 
as  well  as  the  upper  portions  of  the  thighs.  The  bowels  are  ge- 
nerally confined,  and  occasionally  difficult  to  move ;  and  when, 
this  is  effected,  it  is  for  the  most  part  attended  by  tenesmus. 
Some  have  thought,  this  symptom  arises  from  an  extension  of 
the  inflammation  of  the  bladder ;  but  we  have  never  seen  any 
evidence  of  this;  and  we  think  it  altogether  a  sympathetic  affec- 
tion. It  is  a  little  difficult  at  all  times  to  say  what  portion  of  the 
bladder  is  the  seat  of  the  inflammation,  even  in  the  commence- 
ment of  the  disease ;  nor  is  this  of  much  moment,  as  it  does  not 
influence  the  treatment— but,  as  a  general  rule,  we  would  say, 
it  is  the  neck  of  this  organ  that  is  most  frequently  besieged;  and 
this  for  obvious  reasons.  First,  because  it  is  the  most  active 
portion  of  the  bladder;  secondly,  it  is  the  most  dependent,  and 
confined ;  consequently,  most  likely  to  embrace  and  retain  any 
mechanical  agent,  as  gravel,  sand,  or  calculi  within  its  folds. 
Thirdly,  because  certain  medicines  appear  to  act  upon  this  part, 
as  far  as  can  be  ascertained  by  the  sensation  excited  upon  the 
passage  of  a  catheter  or  bougie.  It  must  nevertheless  be  admitted, 
that  dissection  has  revealed  that  the  body  of  this  organ  has  been 
found  thickened,  as  well  as  ulcerated.  When  the  inflammation 
occupies  the  body  of  the  bladder,  it  may  be  continuously  spread 
to  the  ureters,  and  even  to  the  kidneys.  This  may  produce  an 
entire  suppression,  or  may  cause  a  more  obstinate  retention  of 
urine.  Should  this  happen,  and  an  attempt  be  made  to  pass  either 
a  bougie  or  catheter,  much  pain  will  be  excited ;  and  we  have 
seen  the  trial  followed  by  a  considerable  discharge  of  blood. 

Terminations. 

3017.  An  acute  cystitis,  like  all  the  phlegmasiae,  may  termi- 
nate by  resolution,  by  suppuration,  by  gangrene,  and  by  altera- 
tion of  structure — but  the  mode  of  termination  will  sometimes 
depend  upon  the  vigour  of  the  treatment ;  the  period  at  which 
it  is  employed,  and  the  age  and  habits  of  the  patient. 

Resolution. 

3018.  If  resolution  be  about  to  take  place,  we  find  the  pulse 
becomes  softer,  less  frequent,  and  smaller ;  or  in  other  words, 
an  abatement  of  fever,  and  also  a  diminution  of  pain.     The  skin 


628  CYSTITIS. 

becomes  softer,  cooler,  and  disposed  to  sweat.  The  urine  be- 
comes more  abundant,  is  passed  with  less  difficulty,  and  deposits 
a  sediment.  The  perineum  and  hypogastrium  are  less  painful, 
and  will  bear  moderate  pressure  without  causing  pain. 

Suppuration. 

3019.  It  is  said,  that  suppuration  is  a  rare  termination  of  cys- 
titis ;  we  believe  this  to  be  true,  especially  in  the  acute  form  of 
this  disease;  for  such  is  its  general  violence,  that  ulceration 
takes  place  before  suppuration  can  be  established.     For  when 
this  disease  is  of  an  exalted  character,  the  patient  dies  rather 
from  the  over-distention  of  the  bladder,  than  from  the  conse- 
quences of  inflammation  itself — at  least,  this  was  the  case  in  the 
only  two  instances  we  have  had  the  opportunity  of  examining 
after  death.   But  when  this  mode  of  termination  is  about  to  take 
place,  it  is  announced  by  the  general  precursors  of  suppuration, 
such  as  rigours,  abatement  of  pain  and  fever,  together  with  a 
purulent-looking  substance  mixed  in  the  urine,  which  soon  leaves 
the  urine  and  settles  at  the  bottom  of  the  vessel.    We  have  seen 
this  substance  in  two  instances,  prodigiously  large  in  quantity, 
and  continue  to  be  yielded  for  a  long  time.  We  were  of  opinion 
at  the  time  these  cases  occurred,  that  it  was  the  product  of  the 
mucous  membrane  of  the  bladder.     We  are  however  told,  that 
an  abscess  may  form  in  the  interstitial  coats  of  the  bladder,  and 
break  within  its  cavity,  and  from  thence  be  discharged — we  have 
never  witnessed  such  a  case;  but  we  do  not  deny  it,  as  an  occur- 
rence.    In  such  cases,  we  should  think,  that  the  pus-like  sub- 
stance wowld  not  bear  the  same  aspect  as  that  furnished  by  the 
inflamed  mucous  membrane — it  would  most  likely  be  accompa- 
nied by  a  discharge  of  blood,  or  have  blood  mixed  with  it. 

3020.  We  are  informed,  that  the  matter  has  found  an  outlet, 
through  the  rectum ;  and  has  even  opened  within  the  cavity  of 
the  abdomen,  the  labia  pudendi  of  females,  and  through  the  cel- 
lular structure  of  the  scrotum.     Sometimes  the  mucous  mem- 
brane has  had  the  appearance  of  fungus,  found  thickened,  or 
studded  with  scirrhous  indurations. 

Gangrene. 

3021.  When  cystitis  runs  its  course  rapidly  to  death;  that  is, 
within  six  or  seven  days,  the  bladder  is  said  to  become  gan- 
grenous— we  have  seen  it  ulcerated,  (par.  3019,)  or  as  it  is  ge- 
nerally termed,  burst,  within  that  time ;  but  have  never  seen  it 
absolutely  in  a  state  of  gangrene,  though  we  do  not  dispute  the 
fact,  as  stated  by  authors.    When  this  is  about  to  take  place,  the 


CYSTITIS.  629 

symptoms  that  usually  attend  the  loss  of  life  in  an  important 
viscus,  present  themselves  in  this — namely,  a  sudden  cessation 
of  pain,  clammy  sweats,  small  frequent  pulse,  prostration  of 
strength,  cold  extremities,  cadaverous  countenance,  slight  deli- 
rium, hiccough,  death. 

Causes. 

3022.  The  causes  that  may  produce  cystitis,  are  sufficiently 
numerous ;  among  these  may  be  reckoned,  gravel,  sand,  or  cal- 
culi; blows,  kicks,  or  other  violences.     The  unskilful  introduc- 
tion of  the  catheter  or  a  bougie;  overdose  .of  cantharides,  or  be- 
ing absorbed  from  blistered  surfaces;  turpentine;  overdoses  of 
camphor  or  opium.    Morbid  translations,  or  metastasis  of  gout, 
rheumatism,  repelled  eruptions,  stimulating  injections,  gonor- 
rhoea, suppression  of  hamorrhoidal  discharges,  sudden  check  of 
perspiration,  &c.  &c. 

Treatment. 

3023.  The  practitioner  who  is  easily  alarmed  when  blood  is 
drawn  from  his  patient,  will  rarely  be  successful  in  the  treatment 
of  acute  cystitis,  if  he  carry  these  fears  into  his  treatment ;  for 
there  are  few  diseases  that  ean  spare  it  better,  or  that  requires  it 
more.  It  should  be  freely  drawn  from  the  arm,  especially  in  the 
beginning  of  the  complaint;  and  repeated  again  and  again,  if  the 
state  of  suffering  and  the  condition  of  the  pulse  calls  for  it. 

3024.  Besides  this  general  depletion,  leeches  must  be  liberally 
used;  especially,  when  much  pain  is  felt  in  the  perineum  and 
rectum;  when  the  urine  is  discharged  guttatim,  or  but  in  a  very 
moderate  quantity ;  when  the  pain,  by  the  sensations  of  the  pa- 
tient, is  located  at  the  neck  of  the  madder ;  but  above  all,  when 
ischuria  attends.     We  need  not  regard  either  their  number,  or 
the  quantity  they  abstract  during  the  active  stage  of  this  disease, 
provided  they  are  so  numerous  as  to  occupy  the  whole  face  of 
the  perineum,  portions  of  the  groins,  and  the  verge  of  the  anus, 
and  that  they  abstract  blood  freely.     The  after-bleeding  should 
be  encouraged  by  the  application  of  cloths  wrung  out  of  warm 
water,  or  by  the  application  of  a  soft  bread  and  milk  poultice 
placed  between  the  fold  of  fine  linen.     It  rarely  happens  that  a 
single  leeching  is*  sufficient,  when  symptoms  run  high,  or  the 
disease  been  neglected  in  the  early  stage ;  or  what  is  worse,  im- 
properly treated.  The  leeches  must  therefore,  like  the  bleeding, 
be  repeated,  so  long  as  pain  and  dysury  require  their  application. 

3025.  If  the  bladder  be  distended,  which  can  be  pretty  cer- 
tainly ascertained  by  examining  the  hypogastrium,  by  the  sen- 


630  CYSTITIS. 

sations  of  the  patient,  and  by  the  quantity  of  urine  that  is  dis- 
charged. With  a  view  to  ascertain  this,  we  direct  that  every 
drop  of  water  that  escapes  from  the  urethra  be  collected  in  a 
^urinal — by  this  means  we  may  very  nearly  determine  if  it  be  the 
natural,  or  accustomed  quantity  of  the  patient.  If  we  are  not 
careful  of  the  state  of  the  bladder  as  regards  distention,  much, 
or  perhaps  irreparable  mischief  may  ensue;  therefore,  when  the 
quantity  voided  is  not  sufficient  to  prevent  accumulation,  the 
catheter  should  with  great  care  and  skill  be  introduced,  and  re- 
peated, as  the  exigencies  of  the  case  may  demand. 

3026.  We  are  aware  that  this  direction  requires  great  care; 
but  when  the  distention  is  threatening,  it  is  the  lesser  evil  to  at- 
tempt it,  provided,  the  operator  be  experienced  and  skilful.     It 
sometimes  however  happens  under  the  most  skilful  management, 
that  the  bladder  cannot  be  entered  by  the  catheter ;  either  because 
the  sphincter  of  the  bladder  will  not  yield,  in  consequence  of  its 
engorged  state,  or  because  it  is  excited  to  spasm  :  if  this  obtain, 
force  must  not  be  made  to  overcome  it.     In  the  first  case,  all 
forcible  attempts  to  enter  the  bladder,  should  be  desisted  from, 
and  the  utmost  latitude  and  freedom  be  given  to  antiphlogistic 
remedies,  to  the  very  last  moment  that  can  be  spared  for  their 
trial — the  warm  bath  should  also  be  tried,  before  the  patient  is 
abandoned  to  his  fate ;  for  we  believe  under  the  existing  circum- 
stances of  the  case,  and  condition  .of  the  parts,  any  operation 
would  be  totally  unavailing.  In  the  second  case,  antispasmodics, 
should  be  resorted  to ;  and  as  far  as  success  in  two  cases  will  jus- 
tify the  recommendation,  the  external  application  of  tobacco  to 
the  genitals  and  perineum,  merits  the  preference.     Or  it  might 
be  exhibited  per  anum.     Opium  in  enemata,  should  also  be  held 
in  requisition  or  used  in  the  form  of  a  suppository. 

3027.  Hamilton  has  extolled  the  combination  of  calomel  and 
opium  in  affections  of  the  blWder;  and  we  think  occasionally  we 
may  derive  advantage  from  it,  if  used  at  the  proper  time ;  that 
is,  after  the  reduction  of  the  inflammatory  symptoms ;  but  not- 
before. 

Regimen. 

3028.  During  the  whole  treatment  of  the  inflammatory  stage 
of  this  complaint,  a  strictly  antiphlogistic  regimen  should  be 
persisted  in ;  for  there  are  few  diseases  in  which  it  would  be  so 
unsafe,  to  deviate.     An  ounce  of  animal  substance  in  any  shape 
or  form ;  or  a  single  tea-spoonful  of  any  alcoholic  liquor,  might 
prove  fatal.     None  but  the  mildest  and  most  bland  articles  of 
drink  should  be  given ;  as  barley  water,  gum  water,  rice  water, 
flaxseed  or  slippery-elm  bark  tea,  &c.     All  diuretics  should  be 


CTSTITIS.  631 

withheld,  as  no  stimulation  of  the  kidneys  can  benefit  the  in- 
flamed bladder.  The  drinks  just  suggested,  beside  serving  their 
own  proper  service,  will  also  afford  sufficient  nourishment  for 
the  whole  of  the  active  stages  of  this  disease. 

Chronic.  Cystitis,  Cystirrhcea,  or  Catarrhus  Vesicse. 

3029.  The  acute  inflammation  of  the  bladder,  sometimes  leaves 
its  mucous  surface  in  a  state  similar  to  the  vaginae  of  women,  or 
the  urethrae  of  men,  when  the  one  is  labouring  under  leucorrhoea, 
and  the  other  gleet.   But  it  is  not  always  necessary  to  the  chronic 
form  of  cystitis  that  the  mucous  membrane  of  this  organ,  should 
have  been  preceded  by  active  inflammation.    We  have  certainly 
seen  a  number  of  instances,  to  the  contrary ;  and  where  no  un- 
pleasant symptoms  preceded  the  purulent  discharges  from  the 
bladder;  and  where  this  circumstance  alone  first  attracted  the  at- 
tention of  the  patient — this,  especially  obtains  in  very  old  peo- 
ple, who  are  most  obnoxious  to  this  complaint. 

Symptoms. 

3030.  We  have  witnessed  two  conditions,  of  the  catarrh  of 
the  bladder — 1.  Where  it  was  neither  preceded,  nor  accompani- 
ed by  pain  or  other  inconvenience;  and  2.  Where  pain  existed 
in  a  moderate  degree.     Iti  the  first,  pressure  upon  the  perineum 
or  hypogastrium  produced  no  pain  or  any  other  irritation,  though 
much  purulent  matter  might  attend  each  emptying  of  the  bladder. 
In  this  form  however  as  well  as  in  the  second,  there  is  a  more  fre- 
quent desire  to  pass  water  than  natural,  owing  perhaps,  to  the  pre- 
sence of  pus  within  the  bladder,  or  because,  the  mind  is  directed 
to  this  organ  in  consequence  of  this  discovery,  which  we  know 
has  a  decided  influence  upon  its  functions.    In  the  second  condi- 
tion, some  inconveniences  are  constantly  present;  such  as  pain 
upon  pressure,  though  moderate  in  degree,  both  above  the  pubes, 
and  upon  the  perineum.     A  sense  of  heat  or  burning  in  the  re- 
gion of  the  bladder,  especially  just  before,  as  well  as  immediately 
after  making  water.     A  sense  of  weight  or  bearing  down,  when 
the  patient  is  on  his  feet,  or  when  his  bowels  are  constipated ; 
pain,  but  not  severe,  in  the  testicles,  and  the  small  of  the  back, 
and  loins.  The  stomach  deranged,  by  loss  of  appetite,  belchings, 
nausea,  or  even  vomiting  sometimes.   The-tongue  usually  furred, 
attended  by  a  disagreeable  taste  in  the  mouth,  especially  in  the 
morning.  There  is  almost  always  in  the  second  condition  of  this 
complaint,  some  febrile  excitement — hence,  thirst,  heat  in  the 
hands  and  feet,  and  frequently  partial,  but  copious  sweats.    The 
urine  is  first  found  to  be  rather  whiter  than  natural,  and  is  ob- 


632  CYSTITIS. 

served  to  separate  into  two  portions;  the  supernatant,  is  the 
urine  deprived  of  the  pus ;  and  the  deposit,  the  purulent  matter 
thrown  out  by  the  mucous  membrane  of  the  bladder.  The  quan- 
tity, and  density  of  the  matter  mixed  with  the  urine,  will  vary 
very  much  in  different  individuals,  and  in  the  same  individual  at 
different  periods  of  the  four-and-twenty  hours — it  is  greatest  in 
quantity,  and  in  tenacity,  early  in  the  mornings,  and  especially 
if  sleep  has  been  undisturbed  during  the  night,  by  the  exhibition 
of  an  opiate.  This  is  readily  accounted  for,,  as  the  bladder  has 
retained  its  contents  longer,  and  more  time  is  given  for  the  secre- 
tion, and  consequently,  the  accumulation,  of  the  purulent  matter 
within  it. 

3031.  We  are  told  of  enormous  quantities  of  this  purulent 
mucus  being  discharged,  daily — to  the  amount,  it  is  said,  of  pints. 
We  have  never  however  witnessed  any  thing  like  this  excess ; 
though  in  one  case,  «  gentleman  of  more  than  eighty,  we  esti- 
mated the  quantity  yielded,  and  we  took  some  pains  to  be  ac- 
curate, at  three  half  pints ;  and  this  we  thought  enormous.     The 
mucus  is  of  different  degrees  of  tenacity,  which  appears  to  de- 
pend in  some  measure  upon  the  degree  and  extent  of  leison  the 
mucous  membrane  may  suffer.     Prout  says  '*  it  may  be  drawn 
into  strings"  (when  cool)  "  of  considerable  length,  and  the  vessel 
may  be  frequently  inverted  without  its  falling  out."    When  the 
disease  is  of  long  standing,  or  has  been  preceded  by  high  inflam- 
mation, the  urine  will  sometimes  contain  a  good  deal  of  blood,  or 
there  may  be  even  considerable  hemorrhage.     Dr.  M'Dowell 
says,  "blood  is  often  discharged  in  very  large  quantity;  and  to- 
gether with  the  abundant  mucus,  a  white'  powdery  sediment,  or 
sanious  matter,  is  mixed  with  the  urine." — Dub.  Trans. 

Pathological  Changes. 

3032.  Dr.  M'Dowell,  (Dublin  Transactions,  Vol.  IV.)  found 
in  inveterate  cases,  the  mucous  surface  of  the  bladder  in  "  dif- 
ferent degrees  of  vascularity,  from  merely  a  few  patches  of  a 
dark  or  bright  red  colour  to  an  entire  vascularity;  in  some  cases 
so  marked,  as  to  appear  as  if  the  bladder  had  been  daubed  over 
with  blood ;  the  veins  generally  turged ;  the  membrane  much 
thickened;  frequently  numerous  ulcers  occur,  coVered  with  a 
tenacious  brownish  lymph  ;  these  are  sometimes  deep  and  nu- 
merous, so  as  to  give  a  honey-comb  appearance  to  the  membrane. 
The  inflammation  sometimes  ends  in  complete  sphacelous  of  the 
interior  of  the  bladder." 


NEPHRITIS.  633 


Treatment. 

3033.  This  disease  must  be  regarded  as  a  sub-acute  cystitis, 
and  an  antiphlogistic  plan  must  be  pursued;  the  severity  or 
strictness  of  which,  however  must  be  regulated  by  the  evidences 
of  general  disturbance  of  the  system,  or  by  the  degree  of  local 
irritation.     Where  there  is  any  exaltation  of  the  pulse,  or  much 
local  suffering,  we  may  if  the  first  condition  obtain,  abstract  blood 
from  the  general  system ;  if  the  latter,  from  the  perineum,  and 
verge  of  the  anus,  by  leeches ;  or  by  cups  from  the  upper  inner 
parts  of  the  thighs.     All  liquors,  should  be  especially  avoided ; 
and  all  animal  substances  should  be  refrained  from,  so  long  as 
there  is  any  increased  frequency  in  the  pulse,  or  the  slightest 
febrile  movement  at  any  portion  of  the  day.     When  every  ap- 
pearance of  inflammatory  irritation  has  subsided,  the  uva  ursi, 
balsam  copaiva,  white  turpentine,  the  pipsissewa,   (chimaphila 
umbellata,)  the  buchu  ;*  some  of  the  preparations  of  iron,  either 
alone  or  in  combination  with  some  one  of  the  tonics  above  named 
may  be  tried,  with  a  prospect  of  success.  Dr.  Eberle  informs  us, 
he  effected  a  cure  by  the  tincture  of  iron,  and  the  uva  ursi.     All 
rude  motions,  or  severe  exercises  should  be  avoided. 

SECT.  VIII.— NEPHRITIS. 

Acute  Nephritis. 

3034.  The  kidneys,  like  every  otherxviscus,  are  liable  to  pe- 
culiar affections,  and  from  a  considerable  variety  of  causes.  There 
are  a  number  of  organs  that  sympathize  with  them  when  in  a 
state  of  irritation,  or  of  inflammation — as  the  stomach,  the  brain, 
the  skin,  the  bladder,  the  testes,  &c.     It  is  well  to  bear  this  in 
mind ;  as  it  sometimes  happens,  that  the  seat  of  irritation  is  not 
always  easily  detected,  and  may  even  passwithout  suspicion;  thus 
giving  uncertainty  to  our  therapeutical  means.  Thus,  nephritis  is, 
occasionally,  unattended  by  any  marked  derangement  in  these  or- 
gans; while  the  stomach,  the  brain,  or  the  bladder,  may  exhibit  all 
the  marks  of  an  idiopathic  affection,  while  the  source  of  irritation 
is  the  kidney — in  a  word,  there  are  few  of  the  viscera  that 
have  more  extensive  sympathies.     While  on  the  other  hand,  it 
very  often  reciprocates  with  other  portions  of  the  body.     Each 
abdominal  organ  in  a  state  of  disease,  may  create  much  uneasi- 
ness in  the  kidneys;  and  they  may  even  become  the  seat  of  me- 

*  Much  has  been  said  in  favour  of  the  buchu  in  affections  of  the  bladder; 
more  than  we  have  found  it  to  deserve  in  the  trials  we  have  made  of  it,  in  the 
mucous  discharge  from  the  bladder. 

80 


634  NEPHRITIS. 

tastasis.  They  are  not  however  extremely  prone  to  acute  in- 
flammation, though  liable  to  chronic  affections  peculiarly  their 
own ;  as  calculi,  sand,  and  gravel.  But  when  the  kidneys  are 
attacked  by  acute  inflammation,  it  excites  sufficient  alarm,  though 
it  rarely  fails  to  be  subdued,  by  early  and  judicious  means. 

Causes. 

3035.  Whatever  is  capable  of  irritating  the  pelvis  or  substance 
of  the  kidney,  may  exist  in  such  force  as  to  cause  inflammation — 
thus  the  more  powerful  diuretics  unduly  urged ;  as  cantharides, 
nitre,  camphor,  the  turpentines,  or  the^Harlasm  oil,  the  immode- 
rate use  of  alcoholic  liquors,  stone,  gravel,  sand,  or  other  calca- 
reous matter  blocking  up  the  tubuli  uriniferi,  or  irritating  the 
pelvis  of  the  kidney,  may  give  rise  to  nephritis.     Certain  other 
mechanical  causes  may  also  produce  this  disease;  as   wounds, 
contusions,  tumours,  over-exertion  of  the  muscles  of  the  back, 
violent  jolts  from  riding,  or  from  this  exercise  being  too  long 
continued. 

Symptoms. 

3036.  This  complaint  is  frequently  ushered  in  by  chilliness  to 
which  violent  reaction  sometimes  succeeds;  pain  in  the  lumbar 
region ;  but  this  not  always  intense,  but  can  generally  be  in- 
creased by  pressure  or  motion ;  especially  when  attempting  to 
straighten  the  body.     Instinct,  however,  directs  the  patient  not 
to  attempt  this  unnecessarily  ;  on  the  contrary,  we  find  him  al- 
most always  inclining  to  the  affected  side ;  thus  relaxing  the 
lumbar  muscles.     Hence  he  lies  most  commonly  on  the  pained 
side,  or  upon  his  back.     In  some  instances,  this  disease  is  ac- 
companied by  gastro-enteritis.     The  urine  is  often  tinged  with 
blood,  or  even  bloody  in  the  acute  stage  of  the  disease,  and  but 
small  quantities  are  rendered  at  a  time ;  or  it  nlay  be  even  sup- 
pressed. 

3037.  When  the  inflammation  is  produced  by  a  foreign  body 
in  the  kidneys,  the  fever  is  almost  sure  to  be  higher,  than  when 
provoked  by  other  causes.     In  such  cases,  the  pain  is  more  in- 
tense,* throbbing,  and  the  pulse  full  and  hard.     The  testicle  on 
the  side  of  the  affected  kidney  is  sometimes  violently  retracted; 
when  this  happens  it  is  however  supposed  that  the  principal  seat 
of  irritation  is  in  the  ureter;  or  that  the  inflammation,  if  in  the 
kidney  itself,  is  of  a  less  acute  form.     When  this  takes  place, 

*  M.  Bouillaud  says,  that  pain  does  not  always  attend  inflammation  of  the 
kidneys. 


NEPHRITIS.  635 

the  arterial  system,  as  well  as  the  nervous,  exhibit  the  same  ge- 
neral condition,  as  in  any  severe  phlegmonic  affection  ;  such  as  a 
throbbing,  or  pulsating  sensation  in  the  region  of  the  kidneys; 
dry  skin;  thirst,  constipation,  and  pain,  from  an  erect  position. 
When  the  inflammation  arises  from  gravel  or  sand  in  the  pelvis 
of  the  kidney,  we  frequently  find  sabulous  matter,  or  lateritious 
deposits  in  the  urine,  after  standing. 

3038.  Nausea  and  vomiting  frequently  attend  this  disease. 
When  both  kidneys  are  implicated,  the  quantity  of  urine  is  re- 
duced to  a  very  small  quantity,  and  sometimes  is  entirely  sup- 
pressed ;  this  however  occasionally  occurs  when  the  disease  is 
confined  to  one  of  these  organs,  as  the  functions  of  the  other  may 
be  interrupted  by  sympathy. 

3039.  The  pulse,  in  this  disease,  is  full,  hard,  and   frequent, 
in  the  earlier  stage  of  the  affection  ;  but  should  the  disease  not  be 
obedient  to  well-directed  means,  it  becomes  at  the  end  of  the 
third  or  fourth  day,  reduced  in  both  volume  and  force ;  espe- 
cially, if  the  stomach  shows  strong  evidence  of  sympathy. 

Prognosis. 

3040.  Much  depends  upon  the  success  of  early  remedies  in 
this  disease — if  the  disease  have  yielded  agreeably  to  expectation, 
it  pretty  quickly  subsides,  and  may  be  said  to  be  cured.     We 
should  constantly  inspect  the  urine  during  the  progress  of  this 
disease — if  it  become  abundant,  high-coloured,  and  somewhat 
loaded  with  mucus,  we  may  look  for  a  happy  terminatio*n.  Much 
relief  is  also  experienced,  when  the  flow  of  urine  is  large  ;  but 
this  is  rarely  critical,  without  it  is  coloured,  as  just  stated,  at  the 
same  time.  These  favourable  changes  generally  show  themselves 
before  the  fifth  day ;  but  should  the  symptoms  persist  without 
amendment,  much  may  be  apprehended ;  especially  if  there  be 
stupor,  and  a  dull  heavy  pain  in  the  region  of  the  kidney,  take 
place  of  the  acute,  that  had  previously  existed,  accompanied  by 
chills ;  in  this  case  we  have  reason  to  fear,  that  an  abscess  will 
form,  and  suppuration  ensue. 

3041.  Should  this  occur,  the  matter  may  discharge  itself  in 
one  of  several  ways.     1.  Through  the  pelvis  of  the  kidney  to 
the  bladder  and  urethra.     2.  Into  the  abdomen.     3.  Externally. 
The  disease  however,  like  most  other  local  inflammations,  more 
frequently  terminates  by  resolution.     When  suppuration  takes 
place,  it  is  always  we  believe  at  the  expense  of  the  usefulness  of 
the  kidney,  though  the  other  seems  to  carry  on  the  necessary 
dupuration. 

3042.  This  disease  rarely  destroys  by  itself;  gastritis  is  ge- 
nerally produced  and  sometimes  runs  on  to  destruction.     At 


636  NEPHRITIS. 

othe'r  times,  though  very  rarely,  it  kills  by  inducing  peritonitis. 
Danger  is  necessarily  increased,  if  the  disease  attack  both  kid- 
neys; as  in  this  case,  an  entire  suppression  of  urine  takes  place, 
which  is  almost  sure  to  prove  fatal  in  the  course  of  a  few  days, 
by  inducing  cerebral  irritation.  Dr.  Laing  however  mentions  a 
case,  where  there  was  a  suspension  of  nine  days,  without  proving 
fatal.  I  attended  a  case  with  my  friend  Dr.  Neil,  of  this  kind, 
which  proved  fatal  on  the  sixth  day,  the  suspension  being 
complete  for  four  days.  This  patient  appeared  to  die  from 
cerebral  congestion.  We  would  therefore  say  as  a  general 
rule,  that  the  more  naturally  the  secretion  of  urine  goes  on, 
the  less  the  risk.  The  discharge  of  blood,  though  always  un- 
welcome, because  always  alarming,  is  not  necessarily  a  fatal 
symptom;  especially,  in  the  commencement  of  the  disease,  and 
while  the  pain  remains  rather  acute,  and  the  pulse  active.  Indeed, 
in  a  late  case,  the  free  discharge  of  blood  with  the  urine,  seemed 
rather  to  afford  relief.  But  if  this  occur  after  the  sixth  or  se- 
venth day,  the  pain  having  abated  much,  the  pulse  becoming 
frequent  and  feeble,  we  have  much  to  apprehend. 

Diagnosis. 

3043.  This  disease  is  sometimes  confounded  with  lumbago; 
but  may  be  distinguished  from  it  by  its  not  being  attended  by 
a  diminished  quantity  of  urine,  nausea,  vomiting,  disury,  pain 
in  the  course  of  the  ureters,  and  not  having  an  increase  of  pain 
from  motion,  &c.     It  may  also  be  mistaken  for  inflammation  in 
the  psoas  muscle — in  this  however,  there  is  this  difference.     In 
a  psoas  inflammation,  there  is  much  pain  experienced  by  leaning 
the  body  forward  ;  while  in  nephritis,  it  is  always  relieved;  nor 
is  the  former  accompanied  by  nausea  and  vomiting  as  the  latter 
almost  always  is;  nor  does  the  psoas  inflammation  cause  mictu- 
rition. 

Treatment. 

3044.  The  case  must  be  an  extremely  rare  one,  if  it  be  not 
proper  to  draw  blood  in  the  commencement  of  this   disease. 
We  should  therefore  not  only  abstract  blood  early,  but  also 
freely.*     It  should  be  drawn  pleno  rivo,  and  if  a  disposition  to 

•  "  In  suppressions  of  urine,  whether  merely  inflammatory,"  says  Chesel- 
den,  (Anat.  p.  262,)  "or  from  gout,  or  from  an  inflamed  stricture  in  the 
urethra,  I  have  found  nothing  so  effectual  as  bleeding  and  purging.  In  a  san- 
guine large  man,  where  the  penis  was  too  much  inflamed  to  pass  the  catheter, 
I  took  away  three  times  twenty -four  ounces  of  blood,  and  gave  a  purging  clys- 
ter, and  two  strong  purges,  all  within  the  space  of  twenty  hours,  which  saved 
the  patient,  and  delivered  him  from  excessive  torture." 


NEPHRITIS. 


637 


faint  manifests  itself,  so  much  the  better.  To  insure  this,  is 
sometimes  highly  necessary,  as  it  spares  blood  subsequently,  by 
the  disease  yielding  more  readily.  Indeed,  we  do  very  little 
sometimes,  if  we  do  not  make  a  speedy  impression  upon  the  cir- 
culating system.  The  repetition  of  the  bleeding  must  of  course, 
depend  upon  the  force  and  obstinacy  of  the  disease.  We  should 
never  however  withhold  the  lancet,  while  the  pain  is  severely 
lancinating,  and  the  pulse  active;  we  may  therefore  be  under 
the  necessity  of  repeating  it  iterum  iterumque.  But  should 
the  pulse  not  call  for  a  repetition  of  the  bleeding,  yet  the  pain 
and  other  inconveniences  persevere,  we  must  deplete  still  fur- 
ther by  either  cupping  and  leeching,  and  this  to  be  repeated  if 
pain,  fever,  and  a  very  sparing  quantity,  demand  it.  As  a  general 
rule,  I  prefer  cupping  to  leeching.  When  either  of  these  opera- 
tions are  resorted  to,  the  abstraction  of  blood  should  be  made 
from  over  the  seat  of  the  kidneys. 

3045.  During  this  time  purging  must  not  be  neglected ;  and 
this  may  be  pretty  active.   A  calomel  purge  of  eight  or  ten  grains 
should  first  be  given,  and  followed  if  it  do  not  operate  in  three 
hours,  by  either  of  the  neutral  salts,  or  magnesia  and  salts,  or 
castor  oil.      When  there  is  reason  to  fear  there  is  sand  or  gravel 
in  the  kidney,  magnesia  is  the  most  proper  purge  after  the  calo- 
mel, and  may,  in  combination  with  the  sulphate  of  magnesia,  be 
continued  as  long  as  purging  may  be  necessary,  or  as  long  as  it 
will  be  proper  to  call  the  bowels  into  action  two  or  three  times 
a  day. 

3046.  Much  relief  is  obtained  sometimes,  from  moderately  large 
enemata  of  rich  flaxseed,  or  of  slippery-elm  bark  tea.    And  when 
pain  is  urgent,  after  due  depletion  by  the  lancet,  laudanum  in 
flaxseed  tea*  may  be  given  at  bed-time.    Warm  applications  over 
the  region  of  the  kidneys  afford  much  comfort.     And  for  this 
purpose,  a  large  bladder  partially  filled  with  warm  water ;  or  a 
mush,  or  potato  poultice,  in  a  bag  of  linen  or  muslin,  may  be  ap- 
plied, and  changed  when  too  cool. 

3047.  Blistering  has  always  appeared  a  very  doubtful  pro- 
cess— indeed,  I  never  prescribe  it  in  these  cases,  but  at  the  same 
time  I  admit,  prejudice  may  have  something  to  do  with  their 
proscription,  as  several  respectable  practitioners  approve  their 
employment. 

3048.  The  warm,  and  steam  baths,  have  been  recommended; 
and  perhaps  with  propriety — but  in  the  few  trials  we  have  made, 
we  have  thought  the  patient  poorly  rewarded  for  the  trouble  he 
is  put  to,  in  employing  them. 


•  R.  Tinct.  Thebiac.        -      gut.  Ix. 
Tnfus.  sem.  lin.         -     §ij 
M.  pro  enema. 


Take  Laudanum     -     -      60  drops. 
Flaxseed  tea        -        2  ounces. 
Mix  for  an  injection. 


638  NEPHRITIS. 

3049.  During  the  whole  treatment  of  nephritis,  the  regimen 
should  be  strictly  antiphlogistic.     Diluting  drinks,   as   barley 
water,  flaxseed  tea,  gum  Arabic  water,  slippery-elm  bark  tea, 
should  be  freely  indulged  in.   If  pain  remain  in  the  kidney  after 
the  active  stage  of  the  disease,  be  passed  away,  the  uva  ursi  in 
infusion,  in  the  proportion  of  an  ounce  to  the  pint  of  boiling 
water,  and  this  quantity  used  in  the  course  of  twenty-four  hours, 
is  often  highly  useful.    The  balsam  copaiva  is  also  very  service- 
able, when  every  vestige  of  inflammation  is  removed. 

Chronic  Nephritis. 

3050.  The  acute  state  of  the  nephritis  sometimes  sinks  into  a 
chronic  state ;  but  it  is  not  essential  to  the  latter,  that  the  other 
should  have  preceded  it.     Its  etiology  is  almost  the  same,  if  we 
except  such  causes  as  are  sure  when  applied  to  produce  an  active 
inflammation  of  the  kidneys.     We  have  already  spoken  of  the 
acute  form  of  nephritis,  (p.  3034,  &c.)  which  we  believe  is  far  from 
being  as  frequent  as  the  chronic,  though  much  more  threatening, 
as  well  as  much  more  severe — in  a  word,  it  is  but  in  the  inten- 
sity, and  freedom  from  fever,  that  the  one  differs  from  the  other. 

Symptoms. 

3051.  If  we  abstract  the  condition  of  the  arterial  system,  we 
shall  find  but  little  difference  as  regards  the  most  prominent  symp- 
toms, between  the  acute  and  chronic  nephritis.  We  shall  therefore 
not  repeat,  what  we  have  said  at  page  633,  et  seq.,  par.  3034,  &c. 
We  may  however  add  here,  that  the  chronic  is  not  necessarily 
the  result  of  a  preceding  acute  nephritis  as  intimated,  (par.  3050,) 
above.     The  chronic  form  of  this  disease  often  displays  itself  in 
form  of  a  colic,  and  which  lays  claim  to  the  particular  epithet, 
"nephritic  colic."     This  colic  resembles  the  common  spasms  of 
the  colon,  and  it  is  often  mistaken  for  it;  nor  is  it  always  easy  upon 
a  first  attack,  to  distinguish  the  one  from  the  other.    The  agony 
of  the  one  cannot  well  be  exceeded  by  that  of  the  other.     The 
same  restlessness,  tossing,  and  anguish,  attend  both;  and  the  same 
gloomy  forebodings,  and  hopelessness,  are  common  to  each — 
yet,  there  are  marks,  when  the  disease  is  really  violent,  which 
will  serve  to  distinguish  the  one  from  the  other,  which  we  will 
now  point  out. 

Diagnosis. 

3052.  The  chronic  nephritis  may  be  mistaken  for  a  common 
colic,  or  for  the  acute  nephritis,  especially  the  first,  in  a  first  at- 


NEPHRITIS.  639 

tack,  if  it  be  not  violent;  but  in  a  second,  or  when  the  pain  and 
irritation  are  really  severe,  much  less  obscurity  will  prevail.  If 
the  colic  arise  from  some  irritation  in  the  kidney,  there  will  be 
tenderness  upon  pressure  during  its  continuance,  over  its  region ; 
and  immediately  after  the  abatement,  or  cessation  of  pain,  there 
will  be  for  the  most  part,  a  deposition  of  sabulous  matter,  or  the 
expulsion  of  a  piece  of  gravel  of  greater  or  less  magnitude.  The 
back,  or  lumbar  region,  will  have  a  feeling  of  tenderness,  or  a 
sensation  of  having  been  severely  bruised.  In  common  colic,  it 
is  the  abdominal  parietes  that  remain  tender  after  the  cessation 
of  pain.  In  nephritic  colic,  the  testicle  of  the  side  of  the  affected 
kidney,  is  almost  sure  to  be  retracted.  The  vomiting  which  at- 
tends this  form,  aggravates  the  suffering;  whereas  in  spasms  of 
the  bowels,  it  frequently  affords  relief,  and  sometimes  puts  an 
end  to  the  disease.  In  common  colic  the  urine  is  rarely  affected; 
not  so  in  nephritic  colic — in  this,  it  is  sparing  almost  always; 
sometimes  bloody,  and  occasionally  is  suppressed.  The  pulse  is 
rather  frequent,  and  sometimes  intermittent,  thread-like,  and  in 
one  severe  case,  it  was  extinct  for  several  hours.  The  chronic 
may  be  distinguished  from  the  acute  form  of  nephritis,  by  the 
absence  of  febrile  movement,  and  a  lesser  intensity  of  pain,  un- 
less the  paroxysm  be  excited  by  a  mechanical  irritation  within 
the  kidney ;  when  this  is  the  case,  the  suffering  may  be  equally 
intense,  but  it  will  be  unaccompanied  by  fever. 

Prognosis. 

3053.  Much  will  depend  upon  the  nature  of  the  cause  of  chro- 
nic nephritis,  as  regards  its  issue.  If  it  depend  upon  sabulous 
matter,  this,  as  well  as  small  portions  of  gravel,  may  be  suddenly 
discharged,  and  every  unpleasant  symptom  vanish,  almost  im- 
mediately. A  respected,  and  valuable  friend  of  the  author's,  is 
liable  to  severe  and  repeated  attacks  of  nephritic  colic.  His  suf- 
ferings are  almost  beyond  human  endurance — we  have  seen  him 
dripping  with  cold  sweat,  and  an  extinct  pulse  for  several  hours 
together ;  and  when  he  appeared  to  be  in  the  agonies  of  death, 
he  has  suddenly  exclaimed,  while  passing  urine,  "  I  am  well;" 
and  a  portion  of  gravel  would  be  sure  to  be  found  in  the  vessel.  If 
however,  a  calculus  should  occupy  the  pel  vis  of  the  kidney  or  ure- 
ter, the  sufferings  are  both  extreme  and  long-continued,  and  the 
issue  necessarily  doubtful,  as  we  have  it  not  in  our  power,  with 
any  thing  like  certainty,  to  remove  the  cause.  Nature,  however, 
sometimes,  contrary  to  all  human  calculation,  relieves  the  pa- 
tient, by  expelling  from  the  kidney  the  calculus,  through  the 
ureter  and  bladder;  and  from  thence,  through  the  urethra,  with- 
out. We  have  known  this  to  happen  several  times  in  the  same 


640  NEPHRITIS. 

individual — and  each  calculus  was  larger  than  a  common-sized 
pea.  But  notwithstanding  the  temporary  success  of  each  of  these 
efforts,  the  worst  and  most  gloo'my  apprehensions  must  be  enter- 
tained, as  there  does  not  appear  to  be  any  certain  means  in  the 
possession  of  art  to  prevent  the  formation  of  calculi,  or  any 
reason  to  have  a  positive  reliance  on  the  efforts  of  nature.  We 
would  therefore  say,  in  a  few  words,  that  this  disease  is  sure  to 
entail  much  severe  suffering,  and  often  will  eventually  prove 
fatal.  If,  however,  the  sufferings  do  not  proceed  from  a  mecha- 
nical cause,  the  prognosis  may  be  more  favourable.  For  the  dis- 
ease may  be  overcome  if  attacked  by  proper  remedies  before 
structural  derangement  takes  places.  But  should  the  kidney 
continue  to  be  irritated,  it  may  end  in  the  formation  of  calculi; 
it  may  become  tuberculous,  and  agreeably  to  some  late  patholo- 
gists,  "the  kidney  may  be  transformed  into  a  kind  of  sac  which 
may  fill  the  abdomen,  and  which  may  contain  a  variable  quantity 
of  urine.  It  may  produce  scirrhous,  or  cancer  of  the  kidney,  or 
bring  on  dropsy.  Finally,  it  may  give  rise  to  irritation  of  the 
principal  viscera,  to  marasmus,  and  death." 

Treatment. 

3054.  The  same  general  plan  of  treatment  laid  down  for  the 
acute  form  of  this  disease,  should  be  put  in  force  in  this;  that  is, 
leeching,  warmth,  fomentations,  enemata,  mucilaginous  drinks, 
low  diet,  rest  of  body,  and  tranquillity  of  mind. 

3055.  But  should  the  disease  persist,   notwithstanding  the 
vigorous  use  of  these  remedies — that  is,  if  pain  continue,  espe- 
cially down  the  spermatic  cord,  vomiting  .persist,  the  testicle  be 
retracted,  the  feet  and  legs  become  cold,  and  frequent,  micturi- 
tion, we  have  strong  reason  to  believe,  that  a  calculus  occupies 
the  ureter. 

3056.  In  this  case,  the  bowels  should  be  freely  opened  ;  lauda- 
num enemata  should  be  exhibited;  the  solution  of  the  carbonate 
of  soda  should  be  freely  drunk;  the  spirit  of  turpentine,  or  the 
Harlaem  oil,  should  be  given  ;  and  a  strictly  vegetable  diet  should 
be  persevered  in.     In  a  case  we  have  recently  witnessed,  a  sup- 
pository of  opium  seemed  to  answer  better  than  any  other  mode 
of  exhibition  of  the  opium,  that  we  have  tried.     Six  or  eight 
grains,  or  even  more,  according  to  the  emergency  of  the  case,  of 
powdered  opium,  should  be  made  into  the  form  of  an  elongated 
pill,  with  a  rich  mucilage  of  gum  Arabic,  and  be  permitted  to 
dry.     When  sufficiently  hard,  it  should  be  forced  beyond  the 
sphincter  ani  into  the  rectum,  and  allowed  to  remain — this  may 
be  repeated  once  in  four  or  five  hours  if  necessary. 

3057.  To  prevent,  however,  a  repetition  of  this  afflicting  com- 


DIABETES.  641 

plaint,  and  especially  if  there  be  evidence  of  the  presence  of  uric 
acid,  a  strictly  vegetable  diet  should  be  observed;  for  agreeably 
to  Magendie,  this  substance  in  lithic  habits,  is  formed  almost  in 
proportion  to  the  quantity  of  azote  that  is  introduced  into  the 
system  by  animal  food.  A  well-directed  course  of  exercise  should 
be  persevered  in,  and  especially  of  that  kind  that  will  gently  and 
certainly  put  into  action  the  muscles  of  the  back — such  as  sawing 
of  wood,  plaining,  shuttle-cock,  or  battle-door,  &c. 

3058.  But  should  there  be  febrile  excitement,  exercise  must 
be  prohibited ;  the  antiphlogistic  plan  must  be  resorted  to,  and 
thin  diluent,  mucilaginous  drinks,  be  freely  indulged  in;  and 
especially  such  as  possess  a  slight  diuretic  power ;  as  the  infusion 
of  the  watermelon  seed,  or  flaxseed. 

3059.  Should  this  disease  be  the  result  of  repelled  eruptions, 
or  the  drying  up  of  long-established  drains,  the  suppression  of 
habitual  haemorrhage,  as  haemorrhoids,  epistaxis,  &c.  our  atten- 
tion should  be  immediately  called  to  their  re-establishment.  For 
these  purposes,  stimulating  applications,  as  rubifacients,  should 
be  applied  to  the  deserted  parts — if  it  be  to  recall  repelled  erup- 
tions, the  tartar  emetic  ointment  will  be  found  highly  useful;  if  it 
be  to  open  a  dried  up  drain,  as  a*  seton,  or  an  issue,  fresh  ones 
should  be  made;  if  it  be  to  restore  haemorrhoids,  the  continued, 
but  gentle  use  of  aloetic  medicines  will  answer  best ;  if  it  be  to 
restore  a  bleeding  from  the  nose,  the  frequent  snuffing  up  of 
warm  water,  and  an  occasional  pinch  of  snuff,  will  generally 
succeed. 

SECT.  IX. — DIABETES. 

3060.  There  are  no  organs  of  the  human  body,  whose  actions 
are  modified  by  so  many  causes  as  the  kidneys ;  or  whose  pro- 
ducts are  so  varied  by  such  causes.    Thus  we  find,  that  passions 
or  emotions  of  the  mind ;  exercise  or  rest ;  age,  sex,  tempera- 
ment; drinks,  food,  medicines,  temperature,  climate,  secretions, 
excretions,  all  have  an  influence  upon  the  quantity,  the  nature, 
and  appearance  of  the  urine.     Some  of  these  causes,  change  the 
constituent  parts  of  this  fluid  ;  others  alter  its  sensible  qualities ; 
others  augment,  or  diminish,  its  quantity;  while  others,  seem  but 
to  affect  only  its  colour.  But  be  the  change  what  it  may,  it  is  sure 
to  depend  upon  some  alteration,  or  peculiarity  of  the  secretory  ac- 
tion of  the  kidneys  themselves.    Thus  the  constituent  parts  of 
the  urine  are  changed  in  many  instances  with  surprising  prompt- 
ness, as  the  person  may  live  upon  animal,  vegetable,  or  a  mixed 
diet.     A  strictly  animal  diet,  increases  always,  and  sometimes 
seems  almost  to  generate,  the  uric  acid,  by  the  quantity  of  azote 
furnished  by  this  diet — the  vegetable,  destroys  or  prevents,  this 

81 


642  DIABETES. 

acid  ;  while  a  mixed  one,  will  qualify  the  quantity  of  this  article 
in  the  urine.  The  sensible  qualities  are  also  changed;  thus  the 
smell  of  the  urine  after  eating  asparagus,  is  altogether  different 
from  that  of  the  plant  from  which  it  is  derived ;  and,  after  the  use  of 
turpentine,  it  is  that  of  violets.  The  colour  of  the  urine,  is  varied 
by  a  great  variety  of  substances,  as  well  as  its  constituent  parts. 
The  serum  of  the  blood  in  diabetic  subjects,  does  not  yield  the 
sugar,  that  the  urine  is  found  to  possess  in  such  patients,  &c.  All 
this  shows  how  many  causes  may  operate  upon  these  organs  to 
alter  their  natural  or  normal  condition — to  urge  them  to  exces- 
sive secretion ;  to  diminish  it  below  the  healthy  standard,  or  to 
suppress  it  altogether.  But  besides  the  general  causes  just  enu- 
merated that  affect  the  action  of  the  kidneys,  they  are  also  liable 
to  affections  peculiarly  their  own,  and  arising  from  their  proper 
organization  and  functions,  so  that  they  may  well  be  said  to  be 
the  most  mutable  organs  of  the  body. 

3061.  The  disease  called  diabetes,  was  known  to  the  ancients 
but  very  imperfectly;  for  until  about  the  time  of  Willis,  (Cullen,) 
the  sweet  quality  of  the  urine  in  this  disease,  was  not  pointed 
out — hence,  every  inordinate  discharge  of  this  fluid  was  called 
diabetes ;  and  hence  the  imperfect  definitions  of  this  disease.    All 
the  ancient  writers  make  this  disease  ta  consist  in  the  discharge 
of  more  urine  than  of  the  fluids  drunk.     Even  Van  Swieten  does 
not  mention  the  sweet  state  of  the  urine,  though  he  describes 
two  kinds;  "one  wherein  a  great  quantity  of  thin  urine  is  dis- 
charged, equalling  or  even  exceeding  the  drink  taken  in :  the 
other  is  indeed  an  increased  quantity  of  urine,  but  at  the  same 
time  the  thicker  humours  escape  with  it.  The  latter  is  commonly 
with  more  propriety  termed  a  diabetes  by  physicians,  namely,  a 
frequent  and  copious  discharge  of  a  milky  or  chylous  urine.  This 
distinction  has  already  been  given  by  Celsus,  who  divides  too 
great  a  profusion  of  urine  into  thick  and  thin." — Comment. 
Vol.  VI.  p.  151. 

3062.  It  is  evident  from  this  account,  that  the  diabetes  mel- 
litus  as  such,  was  unknown  even  to  Van  Swieten ;  though  both 
he,  and  his  predecessors,  were  aware,  that  the  colour  and  thick- 
ness of  the  urine  in  diabetic  patients,  were  not  always  the  same; 
but  apparently  attributing  more  danger  to  such  discharges  of 
urine,  as  had  the  chylous  appearance,  than  that  which  was  trans- 
parent and  almost  colourless,  though  it  may  have  been  the  genu- 
ine diabetes  mellitus.   Indeed  Cullen  himself,  has  passed  this  dis- 
tinction with  surprising  indifference,  as  in  his  definition  of  this 
disease,  he  does  not  look  upon  it  as  essential. 


DIABETES.  643 

Definition. 

3063.  Diabetes  is  an  immoderate  flow  of  fluids*  from  the 
kidneys;  the  quantity  discharged  by  the  urinary  organs,  exceed- 
ing in  weight,  the  whole  of  the  injesta,  and  holding  in  solution  a 
quantity  of  sugar,  sufficient  to  give  it  a  decided  sweet  taste;  for 
the  most  part  it  is  perfectly  transparent;  of  a  slight  yellow  hue, 
resembling  in  colour  a  solution  of  honey,  which,  together  with 
its  peculiar  sweetness,  gives  this  disease  the  distinctive  name  of 
diabetes  mellitus.     An  unquenchable  thirst  accompanies  this  af- 
fection through  the  whole  of  its  progress,  and  commences  gene- 
rally even  before  the  kidneys  secrete  inordinately.     The  skin  is 
dry  and  husky;  sometimes  scaly;  extreme  emaciation;  and  slight 
chronic  fever  for  the  most  part — its  duration  uncertain  ;  some- 
times killing  in  two  or  three  days ;  at  other  times  continuing  for 
months  or  even  years. 

Division. 

3064.  Authors  have  divided  this  disease  into  two  species;  1. 
into  diabetes  mellitus;  and  2.  diabetes  insipidus.    We  observed 
above,  that  Dr.  Cullen  had  not  thought  proper  to  add  the  honey 
taste  to  his  definition  of  diabetes,  though  he  has  named  it  to  dis- 
tinguish a  species ;  but  by  so  doing,  he  gives  the  idea,  that  the 
sweet  taste  of  the  urine,  is  not  absolutely  necessary  to  a  genus, 
that  we  think  has  no  species.     For  a  mere  increased  secretion  of 
urine,  does  not  constitute  diabetes;  for  were  this  the  case,  we 
should  confound  certain  symptomatic  affections,  with  an  idio- 
pathic  form  of  disease — as  in  hysteria,  gout,  fear,  excess  of  wine, 
teething  in  children,  &c.  We  shall  therefore  confine  our  present 
views  to  that  form  of  diabetes,  in  which  the  discharge  from  the 
kidneys  has  a  sweet  taste  ;  but  were  we  disposed  to  make  a  divi- 
sion of  this  subject,  it  would  be  into  the  acute,  and  chronic.    But 
as  this  would  not  answer  any  good  practical  purpose,  we  shall 
forbear  to  use  the  distinction — for,  the  first,  or  acute  form,  runs 
its  course  with  such  rapidity,  that  any  remedies  that  we  are  at 
present  acquainted  with,  would  be  exhibited  in  vain. 

Symptoms. 

3065.  One  of  the  first  symptoms,  if  not  the  very  first,  is  a 
sudden  dryness  and  thirst,  that  becomes  very  quickly  almost  in- 

*  We  have  chosen  in  this  definition  the  term  "  fluids,"  in  preference  to  that 
of  urine,  because  the  discharges  from  the  kidneys,  of  diabetic  patients,  have 
none  of  the  common  properties  of  urine,  except  its  being  the  product  of  glands, 
that  in  their  normal  state  secrete  this' fluid.  But  while  the  kidneys  are  labour- 
ing under  the  diabetic  action,  they  are  forced  to  yield  a  new  fluid,  but  which  is 
not  urine  by  analysis. 


644  DIABETES. 

supportable.  Indulging  it  by  drinking  scarcely  affords  a  tempo- 
rary relief,  for  it  is  importunately  demanded  so  soon  as  the  pa- 
tient ceases  to  swallow.  In  general  the  discharge  of  urine  if  so  it 
maybe  termed  begins,  soon  after  drinking  any  quantity  of  fluid; 
at  other  times,  the  flow  commences  at  the  time  of  drinking.  The 
patient  complains  sometimes  as  if  cold  water  were  running  from 
the  back  towards  the  bladder;  gastrodinia;  a  burning  in  the  sto- 
mach and  bowels ;  a  pain  in  the  feet  and  calves  of  the  legs.  The 
patient  in  addition  to  his  tantalizing  thirst,  is  also  beset  with  a 
voracious  appetite,  which  the  regimen  to  which  he  is  subjected 
but  ill  satisfies;  especially,  as  it  rather  augments  as  the  disease  ad- 
vances, or  at  least  until  fever  makes  its  appearance.  After  fever 
has  confirmed  itself,  the  patient  for  the  most  part,  pretty  rapidly 
declines ;  the  pulse  becomes  frequent,  feeble,  and  soft ;  debility 
increases  daily ;  in  a  word,  the  febrile  heat  and  other  symptoms 
regularly  exacerbate  towards  evening. 

3066.  The  lips,  the  tongue,  and  throat,  become  very  dry, 
though  smeared  by  a  tenacious  mucus,  or  a  frothy  spittle;  the 
voice  fails  and  becomes  husky.   But  notwithstanding  the  tongue 
may  preserve  its  moisture  natural  to  it,  or  is  frequently  wetted 
by  the  often  use  of  drinks,  the  thirst  diminishes  none.     In- 
deed, the  thirst  is  more  importunate  in  diabetes  than  in  the  most 
ardent  fever. 

3067.  The  urine  at  this  time,  though  pale,  serous  and  clear, 
is  nevertheless  furnished  with  sugar,  and  which  may  be  detected 
not  only  by  the  taste,  but  by  evaporating  a  portion  of  it  to  nearly 
a  state  of  dryness — when  arrived  to  this  state,  or  consistence,  it 
resembles  honey  or  brown  sugar ;  and  when  properly  treated  for 
this  purpose,  a  pure  sugar  can  be  obtained.     If  this  inspissated 
substance  be  exposed  to  the  air,  it  quickly  undergoes  the  vinous 
and  acetous  fermentation.     We  are  told  by  Frank,  that  pure 
crystals  of  sugar  have  been  obtained  from  this  material,  and  that 
eighty  pounds  of  the  urine  have  furnished  twenty-six  ounces  of 
sugary  substance ;  and  others  are  said  to  have  obtained  even  a 
larger  quantity. 

3068.  The  progress  of  diabetes  is  generally  slow;  in  some  in- 
stances, as  we  have  already  observed,  it  will  continue  for  years. 
The  acute  form  of  this  disease  is  still  more  rare  than  the  chronic, 
In  a  case  that  fell  under  the  care  of  Dr.  Chapman,  it  proved  fatal 
in  the  course  of  six-and-thirty  hours;  during  its  continuance, 
many  gallons  of  fluid  wera  evacuated.* 

3069.  During  the  night,  the  discharge  is  more  abundant  than 
during  the  day.  The  nights  of  the  patient  are  nights  of  misery — 

*  Roche  and  Sanson,  (Vol.  II.  p.  121,)  state  that  two  hundred  pounds  have 
been  evacuated  in  twenty-four  hours,  or  twenty-five  gallons. 


DIABETES.  645 

for  so  excessive  is  the  thirst,  so  harassing  is  the  dryness  of  the 
fauces,  and  so  importunate  is  the  desire  to  make  water,  that  the 
patient  can  scarcely  shut  his  eyes,  much  less  can  he  sleep.  De- 
bility creeps  on  apace ;  the  dryness  of  the  skin  becomes  extreme;: 
emaciation  increases ;  oedema  spreads  over  the  feet  and  back ; 
ascites  and  diarrhoea  follow;  and  death,  soon  after,  closes  the 
scene. 

3070.  The  state  of  the  blood  when  drawn,  presents  an  appear- 
ance not  generally  anticipated — namely,  the  inflammatory  crust. 
The  serum,  agreeably  to  some,  has  a  sweetish  taste ;  but  this  is 
denied  by  others,  and  we  believe  with  reason — at  least  it  seems 
to  be  more  generally  admitted,  that  it  is  free  from  this  taste; 
which  renders  the  phenomena  of  this  disease  still  more  interest- 
ing, as  it  gives  to  the  kidneys  the  power  of  generating  this  sac- 
charine matter.     Frank  says  a  ease  of  diabetes  is  recorded,  but 
does  not  indicate  where,  that  alternated  with  a  salivation  from 
the  mouth ;  but  laments,  that  it  was  not  determined  whether  the 
product  of  the  salivary  glands  was  sweet.     We  also  lament  this, 
as  it  would  have  determined  an  important  fact,  especially  if  the 
serum  of  the  blood  had  also  been  tested  in  this  way. 

3071.  Males  are  more  subject  to  diabetes  than  females;  and  it 
is  more  common  with  old  subjects  than  young  men.     Frank 
mentions  a  case,  the  subject  of  which  was  but  eighteen  years — 
we  have  known  it  to  attack  in  one  instance  a  gentleman  wha 
had  passed  his  eightieth  year. 

Proximate  Cause. 

3072.  What  shall  we  say  upon  the  subject  of  the  proximate  cause 
of  a  true  diabetes — a  point  upon  which  all  seem  to  confess  their 
ignorance.  Laxity,  debility,  paralysis,  spasm,  calculi,  &c.  of  the 
kidneys,  have  each  been  the  assigned  cause  of  this  disease;  but 
there  is  as  much  reason,  perhaps  more,  to  believe,  that  either  of 
these  conditions  of  the  kidneys  may  be  the  effect,  rather  than  the 
cause.     Passions  and  emotions  of  the  mind,  the  deranged  state 
of  the  stomach,  the  bowels,  the  liver,  the  lungs,  changes  of  air, 
&c.  have  all  been  looked  upon  as  the  remote  causes,  and  have 
been  resorted  to,  with  a  hope  of  explaining  this  mysterious  dis- 
ease ;  but  with  no  better  reason  or  success  than  the  other  enu- 
merated causes. 

3073.  Dr.  Ayre  looks  upon  diabetes  as  a  chronic  inflammation 
of  the  kidneys;  Dr.  Johnson  thinks  it  cannot  be  attributed  to  the 
deranged  condition  of  any  one  particular  organ,  the  whole  sys- 
tem being  implicated;  while  Dr.  Barry  attributes  it  to  the  con- 
dition of  the  fluids  themselves.  This  discrepancy  shows  the  little 
progress  our  knowledge  of  the  cause  of  diabetes  has  made,  when 


646  DIABETES. 

scarcely  two  pathologists  agree  upon  any  one  of  those  heretofore 
assigned. 

3074.  Several  gentlemen,  (as  Wollaston,  Granville,  Nicholas, 
Marcet,  &c.)  have  attempted  to  throw  light  upon  this  subject, 
by  attempting  to  ascertain  the  chemical  properties  of  the  fluid 
passed  off,  as  well  as  that  of  the  serum  of  the  blood  of  diabetic 
patients.     And  they  appear  to  have  ascertained  a  very  interest- 
ing and  curious  fact  upon  this  subject — namely,  that  the  product 
of  the  kidneys  furnish  sugar,  and  that  the  serum  does  not ;  which, 
if  true,  prove,  that  the  sugar  is  formed  by  the  action  of  the  renal 
vessels  during  the  act  of  secretion.  How,  or  by  what  peculiarity 
or  change  in  their  action,  this  new  product  is  formed,  will  always 
perhaps  remain  beyond  our  powers  to  ascertain,  however  cer- 
tainly we  may  be  able  to  determine  that  more  than  a  certain  altera- 
tion in  the  condition  of  the  system  may  be  necessary  to  pro- 
duce it. 

3075.  Though  we  do  not  feel  ourselves  satisfied  with  any  hypo- 
thesis hitherto  advanced  to  ascertain  the  proximate  cause  of  dia- 
betes, we  cannot  but  admit  that  the  one  offered  by  Dr.  Eberle 
is  as  satisfactory,  and  perhaps  more  ingenious  than  any  we  have 
met  with.     We  shall  therefore  give  his  own  words  upon  this 
subject.  See  Eberle's  Practice,  Vol.  2.  p.  372. 

3076.  "  Whatever  may  be  the  essential  nature  of  diabetes,  or 
the  primary  seat  of  the  disease,  it  appears  quite  certain,  that  the 
proper  functions  of  the  kidneys  are  greatly  deranged  or  pervert- 
ed in  this  disease.  That  this  is  the  case  we  can  admit  of  no  doubt, 
when  we  advert  to  the  circumstance,  that  according  to  the  ex- 
periments of  Nicholas,  Granville,  and  Wollaston,  the  serum  of 
diabetic  blood  does  not  contain  a  particle  of  sugar.     Its  presence 
in  the  urine  can  therefore  only  arisafrom  a  perverted  secretory  ac- 
tion of  the  kidneys;  and  whatever  may  be  the  immediate  cause 
of  the  functional  derangement  of  these  glands,  its  existence  must 
be  regarded  as  the  proximate  cause  of  all  the  characteristic  phe- 
nomena of  the  disease.     Another  pathological  condition,  though 
less  demonstrable  than  the  former,  is,  I  conceive  a  peculiar  con- 
dition of  the  blood,  whic"h  may  perhaps  exist  as  the  immediate 
cause  of  the  perverted  renal  action.     That  the  constituent  ele- 
ments of  the  blood  are  not  such  as  they  are  wont  to  be  in  health, 
is  rendered  probable  by  the  effects  which  the  different  kinds  of 
aliment  have,  both  on  the  saccharine  quality,  and  quantity  of  the 
urine.   If  by  an  exclusive  use  of  animal  diet,  the  secretion  of  urine 
becomes  less  copious,  and  its  saccharine  character  disappears,  the 
inference  naturally  is,  that  by  this  kind  of  food  the  elements  of 
sugar  are  reduced  in  the  blood,  and  consequently  less  abundant- 
ly combined  by  the  perverted  action  of  the  kidneys.     In  health 
there  is  always  more  or  less  urea  secreted  by  the  kidneys,  but 


DIABETES.  647 

in  diabetes,  this  peculiar  urinary  compound  is  rarely  formed  in 
any  appreciable  quantity,  and  very  often  none  at  all.  When  we 
take  into  view  the  close  chemical  analogy  which  exists  between 
this  substance  and  sugar,  it  appears  extremely  probable  that  the 
urea  which  is  secreted  in  health,  is,  in  diabetes,  converted  into 
sugar  by  the  perverted  action  of  the  kidneys.  According  to  the 
analysis  of  Prout,  for  instance,  urea  and  sugar  are  composed  of 
the  following  constituent  elements. 

Urea.  Sugar. 

6.5  Hydrogen  -  6.5  Hydrogen 

20.5  Carbon  -  40.0  Carbon 

26.5  Oxygen  *•''"  54.0  Oxygen 

46.5  Azote    ?•  •  -  Azote 

3077.  "  Thus  the  absolute  quantity  of  hydrogen,  in  a  given 
weight  of  sugar  and  of  urea  is  precisely  the  same ;  while  the 
quantities  of  carbon  and  oxygen  of  sugar  are  just  double  those  of 
urea.  From  all  this  it  would  appear  probable  that  diabetic  blood 
is  deficient  in  azote,  in  consequence  of  which  the  kidneys  are 
not  furnished  with  a  sufficient  quantity  of  this  element  to  form 
urea,  of  which  it  constitutes  a  large  constituent  part;  and  there- 
fore sugar,  which  contains  no  azote,  is  the  result  of  the  renal  ac- 
tion.    This  idea,  first  started  I  believe  by  Wollaston,  is  render- 
ed still  more  probable  by  the  effects  which  an  exclusive  animal 
diet  has  in  reducing  the  quantity  of  sugar  in  the  urine  and  in- 
creasing the  formation  of  urea;  for  the  large  proportion  of  azote 
which  animal  food  furnishes  to  the  blood,  supplies  this  element 
in  sufficient  proportion  for  the  formation  of  urea  by  the  kidneys, 
in  consequence  of  which  the  secretion  of  sugar  is  either  much 
diminished,  or  wholly  arrested.     From  these  observations  it  is 
quite  probable,  as  I  have  already  stated,  that  the  blood  itself  in 
this  disease,  is  defective  in  the  regular  proportions  of  its  healthy 
constituent  elements.     But  here  we  are  necessarily  led  a  step 
further  in  our  inquiries  into  the  pathology  of  this  malady.  What 
is  it,  namely,  that  causes  this  defective  or  innormal  condition  in 
the  composition  of  the  blood?     We  can  think. but  of  one  cause; 
and  that  is,  a  defect  in  the  digestive,  but  more  especially  of  the 
assimilative  functions  of  the  system.  Thus,  then,  it  would  appear 
that  diabetes  is  a  disease  by  no  means  local  or  confined  in  its  pa- 
thological state — but  on  the  contrary  one,  in  which  the  digestive 
and  assimilative  functions,  the  state  of  the  blood,  and  the  parti- 
cular functions  of  the  kidneys,  are  all  deeply  and  essentially  im- 
plicated." 

3078.  "  After  all  our  views  concerning  the  pathology  of  this 
mysterious  disease,  are  as  yet  in  great  measure  conjectural.  In  this 
uncertain  state  of  our  knowledge,  therefore,  I  may  be  allowed 


648  DIABETES. 

to  throw  out  a  conjecture  on  this  subject  which  must  be  left  for 
future  inquiries  either  to  refute  or  confirm.  It  is  well  ascertain- 
ed, that  the  bile  contains  a  very  considerable  portion  of  saccharine 
matter,  called  picromel.  May  not  a  morbid  condition  of  the 
liver,  by  which  this  constituent  of  the  bile  is  prevented  from 
being  formed,  give  rise  to  the  vicarious  secretion  of  a  similar 
substance  by  the  kidneys,  and  thus  produce  diabetes?  An  accu- 
rate analysis  of  the  bile  of  a  diabetic  patient,  would  throw  much 
light  upon  this  point;  and  until  this  is  done,  it  must  remain  en- 
tirely hypothetical.7' 

3079.  Frank  mentions  an  instance,  in  which  the  urine  of  a  con- 
sumptive patient  was  highly  charged  with  saccharine  matter — this 
was  so  abundantly  so,  that  two  pounds  of  the  fluid  yielded  six  ounces 
of  sugar.     Whether  this  is  a  solitary  instance  of  the  kind,  he 
could  not  say,  as  he  never  repeated  the  experiment.   In  this  case 
however,  the  urine  was  not  more  abundant  than  ordinary,  seem- 
ing to  prove  that  the  augmented  quantity  of  fluid  in  diabetes 
does  not  exclusively  depend  upon  the  kidneys  furnishing  the 
saccharine  principle.     It  might  be  well  for  some  accurate  che- 
mist to  undertake  the  analysis  of  the  urine  of  phthisical  pa- 
tients.* 

Anatomical  Characters. 

3080.  "  The  kidneys  are  at  times  found  red,  and  unusually 
large;  at  others  they  present  a  remarkable  degree  of  flaccidity ; 
their  vessels  are  occasionally  considerably  distended  with  fluid, 
dilated,  and  easily  torn ;  in  other  instances  their  substance  has 
suffered  a  sort  of  disorganization  or  solution,  more  or  less  com- 
plete. Again  they  have  been  found  smaller  than  natural."  Mar- 
tinet's Manual  of  Pathology. 

3081.  In  a  case  that  fell  under  the  care  of  Dr.  Baillie,  "the 
veins  upon  the  surface  of  the  kidneys,  were  much  fuller  of 
blood  than  usual,  putting  on  an  arborescent  appearance.  When  the 
substance  of  the  kidney  was  cut  into,  it  was  observed  to  be  every 
where  much  more  crowded  by  blood-vessels  than  in  a  natural 
state,  so  as  in  some  parts  to  approach  to  the  appearance  of  in- 
flammation.    Both  kidneys  had  the  same  degree  of  firmness 
to  the  touch  as  when  healthy ;  but  I  think  were  hardly  so  firm 
as  kidneys  usually  are,  the  vessels  of  which  are  so  much  filled 
with  blood." 

3082.  Dr.  M'Intosh  says,  "  I  have  seen  two  dissections  in 

*  Dr.  M'Intosh  says,  "a  curious  fact  may  be  mentioned,  which  was  first 
stated  by  Cheselden,  and  is  mentioned  at  page  139  of  his  anatomy;  viz.  that 
sweet  urine  is  sometimes  secreted  in  cases  of  chronic  carbuncle."  I  have 
searched  for  this  statement,  but  cannot  find  it  in  the  Ed.  of  Cheselden  I  possess. 


DIABETES.  649 

which  the  kidneys  to  all  appearance  were  in  a  healthy  state, 
and  in  which  the  lungs,  and  the  mucous  membrane  of  the  sto- 
mach, and  a  great  portion  of  the  bowels  were  diseased;  the  for- 
mer being  tuberculated,  and  the  latter  vesicular;  the  vessels 
gorged  with  dark  blood,  and  the  membrane  itself  soft  and 
pulpy."  Mr.  Cruikshank,  says  the  arteries  of  the  kidneys  are 
generally  enlarged  in  this  disease,  particularly  those  of  the 
cryptse  or  minute  glands,  which  secrete  the  urine. 

Pathology. 

3083.  The  pathology  of  diabetes,  Dr.  M'Intosh  has  reduced 
to  the  four  following  heads: — "  1st.  Upon  a  morbid  condition  of 
the  stomach,  or  other  viscera  connected  with  the  assimilation  of 
the  blood,  and  chylification.  2d.  On  the  imperfect  animalization  of 
the  blood.  3d.  Upon  a  retrograde  action  of  the  lymphatic  ves- 
sels. 4th.  Upon  a  morbid  condition  of  the  kidneys  themselves." 
To  all  and  each  of  which,  so  many  exceptions  may  he  urged,  that 
neither  can  be  considered  as  the  true  cause  of  diabetes.  And  I 
shall  conclude  my  observations  upon  this  point,  in  the  words  of 
Dr.  M'Intosh,  as  they  every  way  declare  my  own  experience  in 
this  disease.  "  It  is  difficult  for  me  to  form  any  pathological 
opinions  from  the  discordant  facts  which  have  been  recorded  re- 
specting this  disease,  having  had  no  opportunity  of  investigating 
the  matter  with  the  advantage  of  a  knowledge  of  what  has  been 
done  by  others.  Guarding  myself,  however,  against  the  effects 
of  the  special  pleading  of  many  writers  on  this  subject,  I  cannot 
help  coming  to  the  conclusion,  that  the  truth  may  lie  between 
the  two  extremes ; — that  pathologists  have  been  too  anxious  to 
attribute  the  disease  to  one  particular  organ ; — and  that  those 
who  object  to  the  view,  that  the  kidneys  are  the  seat  of  the  dis- 
ease, have  probably  expected  to  find  some  very  uncommon  dis- 
organization or  vascular  turgescence.  I  am  inclined  to  believe, 
that  diabetes  is  a  functional  affection  of  the  kidneys,  produced  by 
circumstances  which  rarely  exist,  otherwise  the  disease  would  be 
of  far  more  frequent  occurrence  ;  and  that  we  may  look  for  that 
combination  to  the  functions  of  the  stomach,  and  other  organs 
connected  with  digestion,  and  also  to  those  of  the  lungs;  and  if 
this  be  admitted,  there  can  be  no  difficulty  in  perceiving  that  the 
constitution  of  the  blood  must  suffer  some  alteration,  and  that  the 
functions  of  the  nervous  system  must  likewise  be  considerably 
embarrassed."  Practice  of  Physic,  Vol.  II.  p.  285. 

Prognosis. 

3084.  The  prognosis  in  this  intractable  disease,  must  almost 

82 


650  DIABETES. 

necessarily  be  unfavourable.  The  number  of  deaths  from  this 
disease,  very  far  exceed  the  recoveries — yet  cures  have  been  ef- 
fected, which  should  prevent  entire  despondence.  Frank  tells 
us  he  succeeded  in  two  instances ;  but  in  one  a  relapse  took  place, 
which  carried  the  patient  off — the  other  returned  home  appa- 
rently in  good  health.  We  know  of  but  one  instance  of  recovery 
of  this  disease  in  this  place.  It  is  now  several  years  from  the 
first  attack;  but  the  patient  is  obliged  to  adhere  to  the  very 
strictest  diet  of  animal  food,  or  he  is  immediately  threatened 
with  a  return  of  this  affection — in  this  instance,  the  disease  may 
be  considered  as  being  merely  kept  in  subjection,  rather  than 
cured.  The  disease  is  of  more  easy  management  in  young  per- 
sons than  in  old;  and  if  complicated  with  other  affections,  the 
prospect  of  success  is  still  more  diminished.  In  a  word  it  is  one 
of  those  diseases  in  which  the  practitioner  should  never  promise 
success. 

Treatment. 

3085.  The  pathology  of  this  disease  is  so  little  settled,  or 
understood,  that  almost  every  practitioner  will  be  governed  by 
the  views  he  has  taken  of  its  nature.     Such  as  believe  it  to  be 
a  disease  of  debility,  will  give  tonics,  and  other  stimulants;  while 
those  who  look  upon  it  as  essentially  inflammatory,  will  bleed, 
and   use   other  antiphlogistic  means.     Dr.  Watt  of  Glasgow, 
bleeds  repeatedly  in  this  disease,  and  he  has  been  imitated  in 
other  parts  of  Europe,  as  well  as  followed  here.     There  would 
appear  stronger  evidence  in  favour  of  this  practice,  when  ac- 
companied by  a  diet  absolutely  animal,  than  any  other  hitherto 
proposed ;  and  the  only  instance  of  cure  of  this  disease,  if  the 
case  mentioned  above  can  be  considered  a  cure,  was  managed 
in  this  way.   But  in  employing  venesection,  we  must  in  this  dis- 
ease as  well  as  in  every  other,  be  governed  by  the  state  of  the 
system,  as  we  have  constantly  inculcated  throughout  this  work. 
For  to  treat  every  case  of  diabetes  by  blood-letting,  would  be 
to  resign  all  distinction,  and  embrace  empiricism  in  its  great- 
est latitude.     While  on  the  other  hand,  it  would  be  equally 
preposterous  and  injurious,  if  debility  be  considered  the  proxi- 
mate cause,  to  neglect  the  indications,  which  a  full,  tense  pulse, 
present,  and  confine  the  treatment  exclusively  to  tonics  and  sti- 
mulants. 

3086.  We  however  should  be  cautioned  against  the  hasty  con- 
clusion, that  the  pulse  in  diabetes  does  not  present  the  firmness 
or  fulness,  that  would  justify  the  loss  of  blood,   by  making  an 
appeal  to  a  case  related  by  Dr.  Watt.     In  this  case  the  pulse  was 
not  only  slow  and  irregular,  but  was  also  feeble.     The  strength 


DIABETES.  651 

of  the  patient  was  greatly  prostrated  ;  the  lower  extremities  cold 
and  cedematous.  The  blood  when  drawn  was  very  dark,  with  a 
pitch-like  crassamentum,  and  altogether  deprived  of  its  natural 
tenacity.  Yet  in  this  case  Dr.  Watt  freely  employed  the  lancet. 
This  operation  was  repeated  no  less  than  six  times — and  on  the 
fourth  bleeding, the  blood  began  to  show  some  change;  the  cras- 
samentum had  become  dense,  and  its  surface  had  a  buffy  coat. 
On  the  fifth  bleeding,  the  sizy  appearance  on  the  crassamentum 
became  contracted  to  the  size  of  a  shilling;  at  the  sixth  opera- 
tion this  was  still  firmer,  and  the  serum  was  found  of  a  milky 
appearance.  The  patient  experienced  relief  after  each  bleeding, 
and  eventually  recovered  with  difficulty. 

3087.  In  Magendie's  Journal,  (for  1828,)  there  is  a  case  re- 
lated also  of  recovery  after  bleeding,  and  a  strictly  animal  diet; 
together  with  the  use  of  limewater  and  milk,  and  the  hot  bath 
every  evening.     Dr.  Ayre,  (par.   3073,)  warmly  recommends 
leeching  over  the  region  of  the  kidneys,  and  regards  it  as  a  very 
effectual  mode  of  treatment.  This  recommendation  however  arises 
from  the  fortunate  result  of  a  single  case.     Cupping  might  be 
substituted  for  leeching,  where  the  latter  may  be  difficult,  or  in- 
deed it  might  in  our  opinion  even  merit  a  preference.     What 
would  be  the  effect  of  caustic  issues  over  the  seats  of  the  kidneys? 

3088.  Dr.  Ferriar  relates  a  case,  which  was  successfully  treat- 
ed by  the  use  of  bark  and  elixir  vitriol ;  hence  tonics  have  been 
employed.  Dr.  Warren  recommends  opium ;  and  Dr.  Prout  con- 
siders it  the  best  remedial  agent,  especially  in  the  form  of  Dover's 
powder.     Dr.  Prout  gives  some  curious  facts  on  the  power  of 
opium  upon  the  specific  gravity  of  the  urine — increasing  it  at 
first,  but  eventually  it  is  restored  to  its  natural  density.     The 
muriate  of  iron  has  been  extolled  ;  so  has  alum  by  the  German 
practitioners.     Uva  ursi  in  combination  with  Dover's  powder 
has  been  successful  it  is  said.  Dr.  Trotter  has  praised  magnesia ; 
and  it  has  been  considerably  employed  by  the  British  physicians. 
Emetics,  it  is  declared  has  been  useful ;  especially  the  ipecacu- 
anha.    So  also  carbonate  of  ammonia;  the  ammonia  sulphura- 
tum.     Blisters  over  the  region  of  the  kidneys — sp.  tereb.,  mer- 
cury, flowers  of  zinc,  cuprum  ammoniacum,  digitalis,  and  a  hun- 
dred other  articles  of  the  materia  medica  have  been  resorted  to, 
tried,  and  praised ;  repeated,  and  condemned ;  all  only  showing 
the  uncertainty  of  any  mode  of  treatment  hitherto  proposed;  and 
the  necessity  of  seeking  other  means,  to  arrest  this  obstinate  dis- 
ease.    Dr.  Sharkey  recommends  a  drachm  of  the  phosphate  of 
soda,  every  morning  noon  and  evening — he  declares  he  has  seen 
decided  advantage  from  this,  even  after  the  plan  of  Rollo  had  una- 
railingly  been  pursued. 


652  ENURES1S. 


Regimen. 

3089.  However  discordant  the  views  of  physicians  may  be  in 
regard  to  the  proximate  cause  of  diabetes,  and  the  mode  of  re* 
moving  it,  they  are  nevertheless  pretty  unanimous  in  recom- 
mending an  entire  animal  diet  in  diabetes  mellitus.  As  far  as  our 
own  observations  have  extended,  (but  we  admit  them,  limited,) 
this  kind  of  diet  is  the  only  one,  that  has  given  check  to  this  dis- 
ease.    Almost  any  of  the  fresh  animal  substances  may  be  se- 
lected— as  beef,  mutton,  lamb,  poultry,  game,  eggs,  or  oysters 
and  fish.     The  best  drink,  plain  water.     Early  hours,  and  early 
rising;  regular  exercise,  on  foot  especially,  and  without  fail ;  the 
feet  well  protected  against  damp  or  moisture; -flannel  next  the 
skin,  and  decidedly  warm  clothing. 

SECT.  X. — ENTJRESIS,  OR  INCONTINENCE  OF  URINE. 

3090.  The  action  of  the  bladder  in  its  healthy  state  is  almost 
always  under  the  controul  of  the  will;  yet  such  is  its  nature  or 
OBConomy,  that  it  is  pretty  sure  to  force  the  will  to  its  purpose, 
whenever  it  becomes  distended  beyond  a  certain  degree.     This 
wholesome  warning  is,  however,  sometimes  neglected  beyond 
proper  endurance,  by  which  sengfe  penalties  are  sometimes  in- 
flicted, in  consequence  of  the,3$cessive  distention  to  which  this 
want  of  obedience  to  its  dictates,  (if  we  may  term  the  desire  or 
call  to  pass  water,)  necessarily  subjects  this  organ;  for  if  this  be 
carried  beyond  a  certain  point,  the  will  loses  its  influence  over 
the  sphincter,  or  this  part  becomes  deprived  of  the  power  to  obey 
it,  however  anxiously  or  powerfully  it  may  be  exerted.     When 
the  necessity  to  empty  this  viscus  arrives,  it  gives  warning,  and 
is  for  the  most  part  obeyed — or  is  for  a  while  delayed  with  im- 
punity, as  necessity,  convenience,  or  decency  may  exact.     In 
this  respect  man  differs  from  every  other  animal ;  for  none  but 
he  disobey  this  importunate  call,  beyond  the  moment  it  is  felt, 
if  the  animal  be  left  to  its  own  direction. 

3091.  The  frequency  of  the  necessity  to  void  urine,  will  very 
much  depend  upon  the  nature  of  the  aliment  and  drinks  of  the 
individual ;  upon  exercise,  and  last,  though  not  least,  habit. 
There  is  an  error,  not  very  unfrequently  committed,  under  the 
persuasion  that  we  should  never  neglect  to  pass  urine  the  instant 
the  inclination  for  this  purpose  is  felt — for  when  this  kind  of 
obedience  is  too  much  indulged,  a  preternatural  sensibility  is 
created  in  ths  bladder,  and  it  becomes  uneasy  to  discharge  itself, 
before  it  is  half  filled ;  and  this  to  the  great  annoyance  of  the  in- 
dividual who  has  invited  this  habit.     It  is  well  known  to  every 


ENURESIS.  653 

body,  that  many  causes  tend  to  produce  the  inclination  to  make 
water,  besides  the  quantity  of  urine  within  the  bladder — this 
happens  sometimes,  even  a  few  minutes  after  the  bladder  has 
discharged  itself;  and  were  this  sensation*  to  govern,  this  morbid 
sensibility  or  irritability  just  spoken  of,  would  soon  be  generated. 
The  author  is  acquainted  with  several  gentlemen,  who  labour 
under  this  self-imposed  inconvenience,  and  who  informed  him 
it  was  induced  under  a  persuasion  that  the  inclination  to  pass 
water  should,  when  practicable,  instantly  be  obeyed. 

3092.  This,  it  is  true,  may  be  the  minor  evil,  when  compared 
with  mischief  that  might  arise  from  neglecting  too  long  the  call 
for  this  evacuation,  for  death  itself  may  ensue — but  we  would 
advise,  that  neither  of  these  extremes  should  be  wantonly  in- 
dulged.    We  may  however  in  many  instances  so  regulate  this 
discharge,  as  not  to  incur  either  of  the  penalties  just  named  ;  by 
not  yielding  to  the  sensation  at  the  neck  of  the  bladder,  when 
we  know  that  the  inclination  for  its  discharge  does  not  arise  from 
fulness ;  and  consequently,  that  no  mischief  can  ensue,  by  a  tem- 
porary and  well  regulated  delay. 

Definition. 

3093.  Frank  defines  enuresis  "an  involuntary  flow  without 
pain,  of  either  sound,  or  morbid  urine,  through  the  urethra  or 
other  passages." 

Species. 

3094.  The  character  of  this  complaint  is  very  various.  Some- 
times the  urine  escapes  involuntarily  and  without  the  conscious- 
ness of  the  patient — this  is  the  complete  enuresis.     At  other 
times,  it  flows  without  giving  sufficient  warning  of  its  presence, 
and  while  the  patient  is  preparing  to  pass  it — this  is  the  incom- 
plete enuresis.  At  others,  it  only  takes  place  during  sleep — this 
is  the  nocturnal  enuresis.     It  may  depend  upon  some  anormal 
condition  of  the  bladder  itself — this  constitutes  the  idiopathic 
tnuresis.     It  may  arise  from  affections  of  parts  not  immediately 
connected  with  the  bladder — this  is  the  symptomatic  enuresis. 

Diagnosis. 

3095.  This  complaint  cannot  well  be  confounded  with  any 
other — it  is  only  for  diabetes  or  dysuria,  that  it  can  be  taken; 
and  from  these  it  can  be  so  easily  distinguished,  that  nothing  but 
downright  ignorance  would  mistake  the  one  for  the  other.     In 
enuresis,  the  quantity  of  urine  voided  is  vastly  less,  nor  has  it 


654  ENUHESIS. 

the  sweet  taste  of  that  of  diabetes.  It  is  not  accompanied  by  any 
unusual/ thirst,  or  emaciation  of  the  body — it  is  said,  however, 
these  two  diseases  have  been  associated.  (Frank.)  From  dysuria 
it  may  be  distinguished  by  the  pain  and  heat  which  attends  this 
complaint,  when  the  urine  is  passed. 

Symptoms. 

3096.  The  symptoms  attendant  upon  this  disease,  may  be 
collected  from  what  has  already  been  said — but  in  addition  to 
this,  we  may  add,  that  the  person  thus  afflicted,  is  not  only  sub- 
ject to  all  the  inconveniences  attendant  upon  this  weakness,  but 
also  to  the  consequences  of  it.    The  almost  impossibility  to  pre- 
vent the  clothes  from  becoming  imbued  with  the  escaping  urine, 
creates  an   almost  insupportable  odour  from  its  stagnation  in 
them ;  and  thus  unfits  them,  almost  altogether,  from  mixing  with 
society.     Erosions  of  the  genital  organs  and  perineum  quickly 
supervene,  to  add  new  horrors  to  this  disease,  and  thus  to  render 
the  life  of  the  individual  wretched,  beyond  belief.     It  is  true, 
however,  that  every  species  we  have  enumerated,  is  not  equally 
afflicting,  or  equally  difficult  of  management,  as  we  shall  see  pre- 
sently. 

Causes. 

3097.  A  partial  palsy,  or  that  which  confines  itself  to  the 
sphincter  of  the  bladder,  or  a  more  general  one,  as  in  paraplegia 
and  hemiplegia.     Frank  says,  that  a  weakness,  or  relaxation  of 
the  pseudo.-sphincter,*  is  the  cause  many  times  of  enuresis.    An 
exalted  sensibility  of  the  bladder,  negligence  in  not  properly  re- 
gulating the  calls  to  pass  urine,  dreams,  and  bad  habits,  generated 
by  bad  nursing.  A  fall  upon  the  perineum,  a  wound,  a  prolapsus 
of  the  rectum,  or  a  hernia  of  the  bladder,  cutting  for  the  stone. 
In  females,  tedious  and  ill-conducted  labours,  instrumental  deli- 
very, or  the  head  of  the  child  remaining  at,  and  occupying  too 
long  the  lower  strait  of  the  pelvis. 

3098.  Either  of  the  circumstances  just  enumerated,  may  cause 
the  disease  in  question,  by  enfeebling,  or  tearing  the  fibres  con- 

•  What  Frank  means  by  the  pseudo-sphincter  of  the  bladder  is,  we  believe, 
nothing  but  the  levator  ani;  for  the  whole  bladder  is  surrounded  and  covered 
with  this  muscle.  The  neck  of  the  bladder  passes  through  a  slit  in  its  fibres; 
and  while  the  levator  ani  is  acting,  this  slit  is  drawn,  as  it  were,  round  the 
neck  of  the  bladder,  and  thus  for  a  time  prevents  the  urine  from  flowing — it 
is  to  this  arrangement  that  the  urine  and  faeces  do  not  pass  at  the  same  moment; 
and  it  will  therefore  be  easily  perceived,  that  any  injury  done  this  muscle, 
may  very  much  influence  the  action  of  the  bladder,  may  readily  produce  the 
incomplete  enuresis. 


ENURESIS.  655 

stituting  the  neck  or  sphincter  of  the  bladder;  and  it  would  ap- 
pear, from  what  we  can  gather  upon  this  subject,  that  to  produce 
enuresis,  requires  some  local  lesion  or  imperfection  of  this  part, 
if  we  except  perhaps  the  enuresis  of  habit — mere  general  debi- 
lity unaccompanied  by  cerebral  disturbance,  does  not  appear  to 
be  sufficient. 

Complete  Enuresis. 

3099.  This  species  of  enuresis,  (par.  3094,)  is  most  frequently 
found  among  old  people,  and  such  as  are  afflicted  with  paralysis, 
or  have  a  strong  tendency  to  it;  or  such  as  have  some  affection 
of  the  brain  itself;  the  spinal  marrow,  or  simply,  of  the  nerves 
which  enter  into  the  composition  of  the  neck  of  the  bladder.  The 
latter,  strictly  speaking  is  of  rare  occurrence ;  for  the  nerves  just 
spoken  of  are  seldom  affected  alone;  those  going  to  the  other  por- 
tions of  this  body,  are  almost  always  implicated — in  this  case,  a 
palsy  of  the  bladder  may  be  the  consequence,  and  may  thus  some- 
times produce  rather  a  retention  of  urine,  than  enuresis. 

3100.  There  may  however  exist,  some  local  cause,  which  may 
by  its  mechanical  agency  produce  this  partial  paralysis;  as  tu- 
mours in  the  vicinity  of  the  bladder;  caries  or  exostosis  of  some 
portion  of  the  lumbar  column,  &c.     Some  have  ranked  certain 
mechanical  injuries  to  the  bladder  itself  among  the  causes  of  the 
complete,  or  enuresis  paralytica,  as  those  specified  in  par.  3097; 
but  we  believe,  that  neither  of  these  causes  produce  a  paralytic 
condition  of  the  parts  concerned — they  produce  this  disease,  by 
a  destruction  or  injury  of  the  normal  condition  of  the  parts  con- 
cerned in  retaining  the  urine,  and  this  may  consist  of  even  a  loss 
of  substance  at  the  neck  of  the  bladder  by  sloughing;  or  it  may 
be  simply  a  rent  or  wound  without  the  loss  of  substance,  the 
sides  of  which  will  not  meet  so  as  to  heal. 

Prognosis. 

3101.  This  species  of  enuresis  is  rarely  cured;  though  the  pa- 
ralytic condition  of  the  neck  of  the  bladder  in   itself,  is  rarely 
dangerous;  yet  it  is  from  its  permanency,  one  of  the  most  vexa- 
tious, and  loathsome  diseases  that  the  human  body  can  be  afflicted 
with.     When  the  disease  arises  from  "  medicable"  local  causes, 
it  may  however,  sometimes  be  removed — but  the  chances  are  al- 
ways unfavourable;  as  long  pressure  upon  the  nerves  of  the  part, 
may  so  injure  their  functions,  that  all  future  usefulness  is  des- 
troyed. 


656  ENURESIS. 


Incomplete  Enuresis. 

3102.  This  species  of  enuresis,  (par.  3094,)  generally  arises 
from  a  morbid  increase  of  sensibility  and  irritability  of  the  in- 
ternal membrane  of  the  bladder,  and  occurs  to  such  as  encourage 
the  too  frequent  discharge  of  their  urine;  and  to  those  who  are 
not  sufficiently  guarded  upon  this  point,  and  of  which  we  have 
already  spoken,  (par.  3090.)     In  the  one  case,  so  morbid  an  irri- 
tability is  created,  that  the  bladder  will  scarcely  retain  a  drop 
of  urine  within  its  cavity ;  in  the  other,  having  been  once  over- 
stretched, it  also  becomes  too  sensitive,  and  will  resist  distention 
when  it  is  attempted  to  be  carried  beyond  a  certain  point — con- 
sequently, in  both  cases,  the  urine  will  escape  from  the  urethra, 
but  in  different  quantities.   In  the  first  the  urine  will  escape  from 
the  urethra  almost  guttatim  ;  in  the  second,  it  will  be  forced  from 
the  bladder  very  often,  and  this  in  spite  of  every  suggestion  of 
the  will  to  the  contrary. 

3103.  The  urine  sometimes  acquires  an  unusual  degree  of 
acrimony,  by  holding  in  solution  certain  substances,  either  not  na- 
tural to  it,  or  if  natural,  in  too  abundant  a  quantity.  In  this  case, 
the  bladder  is  provoked  to  discharge  itself  more  frequently  than 
is  useful  to  its  healthy  oeconomy ;  but  this  rarely  amounts  to  enu- 
resis or  even  to  dysury,  unless  a  habit  (par.  3090,)  is  generated 
of  frequently  voiding  the  urine,  and  thus  increasing  the  irrita- 
bility of  its  neck. 

3104.  Frank  says,  he  has  known  this  kind  of  inconvenience 
perpetuated  to  all  the  children  of  certain  parents,  who  were  of  a 
gouty,   or  scrofulous  habit.     He  gives  a  very   interesting  ac- 
count of  a  girl  belonging  to  this  family,  whose  enuresis  was  cured 
contrary  to  all  hope,  the  instant  she  began  to  menstruate. 

3105.  It  may  also  be  observed  as  a  fact  of  some  importance 
that  such  persons  as  are  liable  to  calculi  of  the  kidneys,  have  the 
bladder  to  become  preternaturally  irritable  and  cause  a  very  fre- 
quent discharge  of  urine.     Rheumatism,  where  it  is  habitual,  or 
long  chronic ;  or  a  catarrh  of  the  bladder,  will  also  sometimes 
give  origin  to  enuresis.     It  is  also  said,  that  hydatids  within  the 
bladder,  and  ascarides  in  the  rectum,  or  even  according  to  some 
in  this  organ  itself,  have  caused  this  disease. 

Prognosis. 

3106.  The  prognosis  in  this  form  of  enuresis  is  more  favoura- 
ble than  the  preceding,  as  several  of  the  causes  with  proper  at- 
tention may  be  removed,  as  will  be  noticed  when  speaking  of 
the  treatment  of  this  disease. 


ENTJRESIS.  657 


Nocturnal  Enuresis, 

3107.  This  species  of  enuresis,  is  almost  always  in  its  origin 
confined  tq  childhood  ;  and  if  it  be  perpetuated,  it  is  most  fre- 
quently by  habit.  The  commencement  of  this  complaint,  may  be 
dated  from  bad  nursing,  or  from  a  want  of  attention  to  the  man- 
ner or  periods  at  which  this  important  evacuation  is  performed. 
Thus  we  find  extremely  few  cases  among  the  children  of  cleanly 
people,  or  such  as  can  bestow  sufficient  attention  to  their  chil- 
dren, to  form  proper  habits.  The  laborious,  or  negligent  woman, 
places  her  child  in  a  bed  or  cradle,  and  causes  it  to  lie  there  many 
hours  together.     During  this  period,  the  child  passes  its  water 
without  restraint,  and  is  never  perhaps,  educated  in  proper  habits, 
as  regards  the  passing  of  its  urine.   Accustomed  to  pass  its  water 
while  in  bed,  it  will  be  sure  to  continue  this  habit  even  when  the 
practice  is  partially  interrupted,  by  its  being  kept  upon  its  feet 
during  the  day — for,  with  the  bed?  he  associates  his  former 
practice;  and  from  sheer  habit  continues  to  yield  his  water  dur- 
ing the  night.     Where  this  habit  is  completely  established,  it  is 
not  necessary  that  dreaming  of  the  act  should  take  place — at 
least  we  have  interrogated  a  number  of  patients  upon  this  point, 
and  they  almost  all  declare  they  are  not  aware  that  they  dream  of 
the  necessity  of  passing  their  water.     As  far  as  our  inquiries  on 
this  point  have  gone,  we  have  been  led  to  the  conclusion,  that 
with  such  as  dream  of  this  act,  the  habit  of  wetting  the  bed  is 
not  so  confirmed,  and  is  of  more  easy  management;  for  it  is  not 
every  night  that  this  takes  place ;  and  a  little  attention  to  the 
quantity  to  be  drunk  in  the  evening,  will  in  many  instances  pre- 
vent the  occurrence.    In  some  instances,  this  form  of  enuresis  is 
purely  accidental — that  is,  the  patient  may  have  drunk  of  more 
watery  fluid  than  his  usual  wont,  and  have  neglected  to  empty 
the  bladder  before  getting  into  bed ;  the  bladder  of  course  be- 
comes filled  to  an  uneasy  degree,  which  acts  upon  the  sensorium, 
and  a  dream  of  passing  water  is  almost  sure  to  ensue:  and  with 
the  imaginary  flow,  the  absolute  takes  place. 

3108.  Dr.  Prout  is  of  opinion,  that  nocturnal  enuresis  fre- 
quently is  associated  with  alithic  diathesis,  especially  in  "young 
females  with  constitutional  irritability  and  weakness ;  and  in  old 
people,  this  affection  is  associated  almost  always,  with  some  or- 
ganic, or  other  affection  of  the  neck  of  the  bladder,  or  prostate 
gland."     He  is  of  opinion  also,  that  when  water  is  passed  under 
the  influence  of  a  vivid  dream,  that  the  urine  in  such  cases,  is 
generally  found  to  yield  upon  settling,  a  gravelly  deposit.    This 
however,  nor  the  other  opinions  of  Dr.  Prout  just  named,  do  not 
comport  with  our  own  experience.  This  detestable  habit,  agreea- 

83 


658  ENURESIS. 

bly  to  our  own  observations,  is  much  more  frequent  in  the  boy, 
than  in  the  girl ;  and  the  black  children  are  particularly  prone  to 
it.  Where  the  urine  is  passed  in  the  night,  without  being  attended 
with  the  slightest  consciousness,  it  is  of  much  more  difficult  ma- 
nagement, than  when  accompanied  by  consciousness. 

Prognosis. 

3109.  This  form  of  enuresis  is  frequently  susceptible  of  remedy. 

Idiopathic  Enuresis. 

3110.  This  form  of  enuresis,  will  depend  upon  an  anormal 
condition  of  the  bladder  itself;  thus  a  thickening  of  the  parietes 
of  the  bladder  from  stone ;  a  scirrhous  condition  of  them ;  ulcers  of 
the  internal  face  of  this  organ;  fungous  excrescences;  polypus; 
abscess,  &c.    All  these  causes  are  calculated  to  prevent  the  regu- 
lar stay  of  urine  within  the  bladder,  by  preventing  its  regular 
contraction,  or  by  weakening  the  power  of  the  sphincter ;  in 
either  case,  the  urine  will  be  prevented  from  tarrying  the  proper 
time  in  the  bladder. 

Prognosis. 

3111.  The  prognosis  of  this  form  of  enuresis,  must  necessarily 
be  unfavourable,  as  the  affections  themselves  which  give  rise  to 
the  disease,  are  for  the  most  part,  incurable. 

Symptomatic  Enuresis. 

3112.  This   form  of  enuresis  originates  from  the  bladder 
sympathizing  with  other  portions  of  the  body  while  labouring 
under  disease.  Thus  a  cancer  or  scirrhus,  a  dropsy,  tumours,  or 
polypus  of  the  uterus,  may  cause  this  species  of  enuresis;  preg- 
nancy,   scirrhus  of  the   intestines,   mesicolon,   vesicule   semi- 
nales,  &c.  &c. 

f* 

Prognosis. 

3113.  The  chance  of  relief  in  this  form  of  enuresis,  must 
necessarily  depend  upon,   1st.  The  curability,  if  we  may  use 
such  a  term,  of  the  original  disease;  and  2d.  Upon  the  extent 
and  nature  of  the  secondary  affection  in  the  bladder  itself. 

Treatment. 

3114.  The  treatment  of  enuresis  must  be  necessarily  as  diver- 


ENURESIS.  659 

sifted,  as  the  species  themselves.  Some  of  the  causes  of  this 
complaint  may  occasionally  be  removed  or  destroyed,  while 
others  we  are  bound  to  confess,  are  beyond  our  reach.  Thus  in 
the  first  form  of  this  complaint,  we  may  now  and  then  suc- 
ceed in  removing  the  torpid  condition  of  the  nerves  that  supply 
the  bladder,  by  moxa,  blisters,  tartar  emetic  ointment,  or  other 
rubefacients  applied  to  the  spine  ;  or  by  the  extract  qf  the  mix 
vomica,  spirit  of  turpentine,  or  the  tincture  of  cantharides,  given 
internally— but  what  will  relieve  this  affection  when  its  origin 
is  in  the  brain  !  Mr.  Lair  recommends  touching  the  prostatic 
extremity  of  the  urethra  and  neck  of  the  bladder  with  the  tinc- 
ture of  cantharides  by  means  of  a  catheter — he  declares  he  cured 
three  patients  by  this  plan.  Dry  cupping  the  perineum  and  sa- 
crum have  also  been  found  useful. 

3115.  In  the  second  form,  the  habit  which  gives  rise  to  the 
excessive  irritability  of  the  bladder  must  be  given  up,  or  dimi- 
nished as  much  as  possible ;  and  its  effects  remedied,  as  far  as 
may  be  practicable,  by  such  remedies  as  are  known  to  diminish 
this  state  in  the  general  system.     Tonics  will  sometimes  answer 
admirably  well ;  especially  when  aided  by  the  cold  bath.  Opium 
however  we  believe,  is  the  best  general  remedy ;  and  this  used 
in  the  form  of  a  suppository.     The  best  mode  of  forming  these, 
is,  by  working  up  the  proper  quantity  of  opium  with  a  sufficient 
quantity  of  rich  mucilage  of  gum  Arabic,  and  allowed  to  become 
hard.*     One  of  these  suppositories  should  be  used  every  night, 
certainly,  and  oftener  if  necessary. 

3116.  In  the  third,  which  is  for  the  most  part  purely  a  disease 
of  habit,  every  care  must  be  taken  to  interrupt  it.  This  must  be 
attempted,  First,  by  making  the  patient  keep  up  at  night,  as  late 
as  is  compatible  with  his  health.  Second,  prevent  his  taking  any 
fluid  article  after  his  dinner  ;  especially  tea  or  coffee.     Third, 
oblige  him  to  make  water  the  last  thing  before  getting  into  bed. 
Fourth,  give  him  a  hard  mattrass  to  sleep  on,  and  a  sufficient 
quantity  of  bed-clothes,  that  his  skin  may  not  become  cold  during 
the  night.     Fifth,  oblige  him  to  rise  early  in  the  morning,  and 
not  to  indulge  in  a  morning  nap,  unless  he  have  passed  his  water 
upon  waking.     Sixth,  make  him  abstain  from  all  substances  that 
will  afford  much  fluid  in   the  stomach   and  bowels,  as  fruits ; 
but  especially,  melons  and  cucumbers.     Forbid  all  salted  sub- 

*  The  requisite  quantity  of  opium  in  a  given  case,  is  to  be  determined  by 
the  quantity  that  would  be  given  by  the  mouth.  Were  one  grain,  or  twenty 
drops  of  laudanum  the  proper  quantity  to  be  received  into  the  stomach,  it  will 
require  three  grains  of  opium  in  the  form  of  suppository,  and  so  on  with  other 
proportions.  We  would  suggest  however,  in  the  use  of  the  suppository,  that 
it  shall  be  certainly  made  to  pass  beyond  the  sphincter  ani;  for  if  this  be  not 
attended  to,  it  may  be  quickly  expelled. 


660  GONORRHOEA. 

stances,  as  this  will  create  thirst,  and  this  will  be  quenched 
by  drinks.  Seventh,  let  him  resist  during  the  day,  as  long  as  he 
can,  by  an  effort  of  the  will,  the  desire  to  make  water,  when  it 
is  unnecessarily  importunate.  By  this  means  he  will  diminish 
the  frequency  of  calls,  by  thus  abating  the  anormal  sensibility  of 
the  bladder  which  a  too  frequent  compliance  with  its  demands", 
has  generated,  and  what  is  thus  gained  in  the  day,  will  also  be 
profitable  at  night.  Eighth,  let  him  wear  a  Burgundy  pitch 
plaster  over  the  sacrum  ;  and  take  from  ten  to  twenty  drops  of 
the  tincture  of  cantharides,  according  to  age,  three  or  four  times 
a  day,  until  a  slight  strangury  is  produced — and  this  must  be  re- 
newed, as  soon  as  it  has  subsided  by  suspending  the  medicine, 
by  again  recurring  to  the  medicine.  The  balsam  copaiva  has 
also  been  found  highly  serviceable;  so  also  the  spirit  of  turpen- 
tine. Blistering  the  perinaeum,  is  sometimes  highly  beneficial. 

3117.  Where  there  is  reason  to  suspect  a  lithic  diathesis,  the 
patient  should  be  exclusively  confined  to  a  vegetable  diet,  and 
the  use  of  the  alkalies,  and  magnesia. 

3118.  Mr.  Charles  Bell  says,  "incontinence  of  urine  never 
takes  place  but  when  the  boy  is  asleep  upon  his  back;  and  the 
cure  is  a  simple  one.     He  is  to  accustom  himself  to  sleep  upon 
his  face  or  his  side;  the  urine  is  not  passed,  nor  is  he  excited  to 
dream  of  making  water  while  he  keeps  this  position.     The  cir- 
cumstance is  unaccountable,  until  we  reflect  upon  the  position  of 
this  master  spring  of  the  muscles  of  the  bladder — the  sensible 
spot,  a  little  behind  and  below  the  orifice  of  the  bladder. 
When  a  person  lies  upon  his  belly,   the    urine  gravitates    to- 
wards the  fundus ;  but  when  he  lies  upon  the  back,  it  presses' 
upon  the  sensible  spot,  and  distends  that  part  of  the  bladder 
which  is  towards  the  rectum."     Of  the  efficacy  of  this  plan,  I 
cannot  speak  from  any  experience — it  may  be  successful  in  such 
cases  as  are  attended  by  dreams ;  but  these  agreeably  to  our  ob- 
servation, are  the  fewer  number,  (par.  3108.) 


CHAPTER  XII. 

OF  GONORRHOEA. 

3119.  GoNORRHffiA,  or  as  it  is  frequently  called  blennorrhcea  or 
clap,  consists  of  an  inflammation  of  the  mucous  membrane  of 
the  urethra. 


GONORRHOEA.  661 


Symptoms. 

3120.  A  slight  itching  is  first  felt  at  the  extremity  of  the 
urethra,  accompanied  by  a  sense  of  heat  in  some  one  portion  of 
this  canal.     If  the  part  be  inspected,  the  mouth  of  the  urethra 
will  almost  always  be  found  glued  together,  and  if  a  slight  pres- 
sure be  made  upon  this  part,  a  small  portion  of  a  purulent  looking 
fluid  may  be  forced  from  it.  A  more  than  natural  desire  to  make 
water  is  now  experienced,  together  with  an  augmented  sensation 
of  heat,  especially  towards  the  extremity  of  the  canal,  when  the 
urine  is  passing.     These  symptoms  may  be  either  moderate,  or 
extremely  severe.     At  this  time,  the  purulent  discharge  is  soon 
found  to  increase ;  and  this,  almost  always  in  proportion  to  the 
severity  of  the  inflammation  that  has  Besieged  the  mucous  mem- 
brane of  the  urethra.     This  discharge  differs  in  tenacity,  and  in 
colour ;  and  as  a  general  rule,  both  these  circumstances  are  go- 
verned by  the  degree  of  irritation.     If  this  be  slight,  the  dis- 
charge is  thinner  in  its  consistence,  and  less  purulent  in  its  ap- 
pearance— if  the  inflammation  be  great,  the  matter  is  not  only 
thicker,  but  more  intense  in  colour ;  even  green  sometimes;  it  is 
also  more  abundant  in  quantity.  The  ardor  urinse  now  becomes 
excessive,  and  the  desire  to  pass  it  is  almost  incessant.   Chordee* 
now  supervenes;  especially  at  night,  at  which  time  erections  are 
more  frequently  produced,  and  the  penis  is  forced  into  a  bent 
form. 

3121.  The  prepuce  swells,  from  oedema  being  produced,  by 
the  constant  irritation  of  its  inner  surface.     This  sometimes  pre- 
vents its  retraction  over  the  glans,  and  thus  causes  phymosis. 
All  these  inconveniences  are  sure  to  be  increased,  by  all  excesses; 
but  especially  by  venereal  indulgence,  to  which  the  patient  is  for 
the  most  part,  strongly  invited. 

3122.  This  description  rather  belongs  to  the  disease,  when  it 
exists  in  an  aggravated  form  ;  and  of  which  it  is  often  very  diffi- 
cult to  relieve  the  patient ;  especially  such,  as  are  inattentive  to 
the  rules  laid  down  for  their  government,  and  such  as  are  of  a 
lymphatic  temperament,  or  of  scrofulous  habit.  The  whole  tract 
of  the  urethra  becomes  inflamed,  which  diminishes  the  calibre  of 
the  urethra  so  much,  that  the  urine  is  delivered  from  it  with  great 
difficulty  as  well  as  severe  pain.     The  neck  of  the  bladder  be- 
comes seriously  involved,  as  well  as  the  prostate,  and  the  glands 
of  Cowper — when  this  happens,  the  patient  feels  a  deep-seated 

*  Chnrdee  is  a  painful,  and  often  repeated  erection,  arising  from  an  active 
state  of  inflammation  of  the  cellular  tissue  of  the  corpus  spongiosum;  and  from 
it  thus  becoming  unyielding,  the  influent  blood  causing  the  erection,  causes 
the  penis  to  bend  into  a  crooked  shape,  and  thus  creating1  great  pain. 


662  GONORRHOEA. 

and  painful  sensation  in  the  perinaeum,  which  is  augmented  by 
sitting  down,  as  well  as  by  standing,  or  exercise.  The  chordee 
is  now  particularly  importunate  during  even  the  day,  arid  pre- 
vents sleep,  during  the  night. 

3123.  In  intemperate  subjects,  and  in  careless  habits,  abscesses 
form,  which  suppurate  and  leave  sometimes  fistulous  openings; 
or  what  is  perhaps  still  worse,  permanent  derangement  of  the 
prostate,  and  the  urethra  itself.     The  testes  become  very  pain- 
ful sometimes,  when  the  inflammation  is  high  in  the  mucous 
membraneoftheurethrajandtheinguinalglandsbecomeswollen — 
constituting  the  sympathetic  bubo. 

3124.  At  other  times,  the  disease  is  every  way  much  milder; 
owing  either  to  the  want  of  susceptibility  in  the  mucous  membrane 
of  the  urethra  or  to  a  less  stimulating  quality  of  the  morbid  matter. 
When  this  happens,  the  patient  comparatively  suffers  but  little ; 
and  the  disease  if  not  provoked  by  errors  in  diet,  or  by  indul- 
gence in  the  venereal  act,  or  want  of  cleanliness,  will  sometimes 
wear  itself  out. 

3125.  In  the  female,  the  sufferings  are  less  intense,  though  suffi- 
ciently so,  when  it  occupies  or  is  confined  to  the  urethra — this 
however  we  believe  is  rarely  the  case ;  as  the  matter  of  gonorrhoea 
is  constantly  offered  to  the  external  face  of  the  vaginal  mucous 
membrane,  as  it  distils  from  the  urethra.*     Yet,  this  disease 
is  frequently  more  difficult  to  subdue  in  the  female,  than  in  the 
male ;  owing  most  probably  to  the  extensive  mucous  surface  that 
is  presented  to  the  discharge  from  the  urethra,  and  perhaps  in 
some  instances,  from  less  attention  to  cleanliness. 

Diagnosis. 

3126.  In  the  male,  as  well  as  the  female,  gonorrhoea  can  only 
be  confounded  with  the  gleet  in  the  former,  and  leucorrhoea  in 
the  latter;  both  of  which,  as  regards  the  principal  sign,  namely, 
a  purulent  discharge  may  be  mistaken  for  each  other,  as  no  sen- 
sible properties  in  either  will  serve  as  a  basis  for  distinction;  es- 
pecially, as  both   gleet  and  leucorrhoea  may  be  but  the  conse- 
quence of  gonorrhoea.     We  believe,  the  want  of  capacity  to  pro- 
pagate itself,  is  the  only  certain,  or  safe  criterion  to  judge  by. 

•  Swediaur  and  some  others,  think  the  gonorrhoea!  inflammation  never  oc-  . 
cupies  the  urethra  in  the  female;  and  many  think  it  rare;  this  we  believe  to  be 
the  case;  yet  we  know  from  ocular  demonstration,  that  it  sometimes  attacks 
this  canal.  The  vagina  is  certainly  its  most  common  seat,  and  this  for  the  most 
obvious  reasons — reasons,  that  no  force  of  fancy,  nor  desire  of  theorizing,  can 
destroy.  Swediaur  makes  its  location  more  extensive,  and  says,  it  may  attack 
the  clitoris,  round  the  orifice  of  the  urethra,  the  nympha,  the  vagina,  or  the 
inferior  commissure  of  the  labia  and  rapha. 


GONORRHOEA.  663 


Pathology. . 

3127.  The  pathology  of  gonorrhoea  seems  almost  to  force  itself 
upon  us,  by  the  uniformity  of  its  location,  and  the  entire  know- 
ledge of  the  nature  of  the  membrane  which  becomes  affected  both 
in  the  male  and  the  female.     It  has  therefore  been  constantly  re- 
ceived upon  trust,  until  lately,  that  it  is  a  specific  inflammation 
of  the  mucous  membrane  of  the  urethra  in  the  male,  and  also  of 
the  female,  with  the  addition  in  the  latter,  of  its  extending  itself 
within  the  vagina.     But  Sir  Astley  Cooper  had  an  opportunity 
of  testing  its  location  in  the  male,  in  the  person  of  a  criminal 
that  was  executed  while  the  disease  was  upon  him.     Sir  Astley 
says,  "  the  inflammation  had  extended  down  to  the  bulb  of  the 
ufrethra ;  for  an  inch,  or  an  inch  and  an  half  down,  the  urethra  was 
exceedingly  red,  and  there  was  some  effusion  of  matter  on  the 
internal  surface ;  the  urethra  was  also  red  at  the  bulb,  but  not  of 
so  deep  a  cplour.     The  inflammation  therefore,  is  not  always 
confined  to  an  inch  or  an  inch  and  an  half  down  the  urethra,  but 
often  extends  over  the  bulb,  and  in  this  way  produces  strictures." 
Lectures,  p.  462.     Sir  Astley  thinks  the  inflammation  is  of  the 
erysipelatous  kind;  but  of  this  some  doubt  may  be  entertained, 
as  the  discharge  is  too  truly  purulent,  and  often  too  mild,  to  be 
the  product  of  this  particular  inflammation.     He  says,  that  ul- 
ceration  takes  place  occasionally  in  the  mucous  follicles,  but  never 
in  the  urethra  itself;  which  circumstance  we  think  supports  the 
belief,  that  the  inflammation  of  gonorrhoea  is  not  of  the  erysipe- 
latous kind. 

Treatment. 

3128.  The  success  of  remedies  for  gonorrhoea,  very  much  de- 
pends, 1st,  upon  the  stage  of  the  disease  at  which  they  are  em- 
ployed; 2d,  upon  the  strength  of  the  remedies  themselves;  3d, 
upon  the  constitution  or  the  temperament;  4th,  and  upon  the  habits 
of  the  individual  who  maybe  the  subject  of  it.  In  its  mild  form 
it  sometimes  cures  itself. 

3129.  1.  As  the  stage  of  the  disease  is  of  much  consequence 
in  the  treatment  of  gonorrhoea,  we  shall  notice  three  periods ; 
a,  the  incipient ;  5,  the  acm6 ;  and  c,  the  decline,  of  the  inflam- 
mation. In  the  first,  #,  if  it  be  attended  to  with  sufficient  prompt- 
ness, the. inflammation  from  its  moderation  may  for  the  most 
part  be  overcome  by  gentle  astringent  injections ;  and  for  this 
purpose  we  have  scarcely  ever  failed  with  the  acetate  of  zinc,  in 
the  proportion  of  one  grain  and  an  half,  to  the  ounce  of  soft  wa- 


664  GONORRHffiA. 

ter.*  This  is  to  be  used  three  or  four  times  a  day  by  means  of 
a  well  working  penis  syringe ;  taking  care  to  pass  urine  imme- 
diately before  throwing  up  the  injection.  We  think  this  pre- 
caution of  great  importance,  though  some  have  been  of  opinion 
that  it  is  useless,  as  the  inflammation  never  extends  beyond  a 
very  limited  distance  within  the  urethra,  and  consequently  agree- 
ably to  them  the  mischief  cannot  be  increased  by  the  matter  of 
gonorrhoea  being  driven  further  into  this  canal..  Now  we  have 
just  stated  upon  the  authority  of  Sir  Astley  Cooper,  that  it  pene- 
trates to  the  bulb ;  and  in  the  case  above  related,  it  occupied 
seven  inches  of  the  urethra.  Care  should  always  be  taken,  that 
the  pipe  of  the  syringe  be  not  introduced  too  far  into  the  urethra 
when  the  injection  is  about  to  be  thrown  up,  as  much  injury  is 
sometimes  sustained,  from  a  neglect  of  this  caution — an  eighth 
of  an  inch  within  the  meatus  is  every  way  sufficient  for  all  use- 
.ful  purposes.  If  this  application  be  properly  persevered  in,  it 
will  very  rarely  fail  to  relieve  in  a  very  few  days.  In  good  con- 
stitutions, this  treatment  is  all  that  is  necessary,  provided  the 
restrictions  we  shall  lay  down  for  either  period  of  the  disease  be 
strictly  conformed  to,  as  a  neglect  of  these  may  give  an  oppor- 
tunity to  inflammation  to  extend  itself,  as  well  as  to  become 
aggravated. 

b^  Its  Jlcmi. 

3130.  In  the  more  virulent  instances  of  this  disease,  the  in- 
flammation becomes  very  severe,  and  causes  much  distress.  The 
discharge  becomes  excessive,  and  is  even  sometimes  tinged  with 
blood.  The  chordee  and  pain  in  the  perinasum  are  much  aug- 
mented, and  the  whole  phenomena  of  the  disease  declare  the 

*  Dr.  Carmichael  is  averse  to  the  early  use  of  astringent  injections,  (for  in 
this  light  we  must  look  upon  the  acetate  of  zinc,)  and  says,  "the  practice  is  at- 
tended with  such  risk  of  exciting  inflammation  of  the  entire  urethra  and  blad- 
der, and  all  the  immediate  as  well  as  secondary  train  of  evils  attendant  upon 
this  calamity,  that  I  have  no  hesitation  in  saying,  that  it  is  a  practice  that  can- 
not be  too  strongly  deprecated."  Notwithstanding  this  sweeping  proscription, 
however,  we  are  in  the  constant  habit  of  employing  the  acetate  of  zinc  in  the 
strength  named  in  the  text  in  the  commencement  of  gonorrhoea,  and  have  been 
for  the  last  thirty  years,  and  we  can  most  truly  say  we  have  never  had  the 
slightest  cause  to  regret  its  exhibition — on  the  contrary  indeed,  we  are  most 
firmly  persuaded  of  both  its  efficacy  and  its  safety;  the  strength  of  the  solution 
should  never  be  greater  than  that  we  have  just  indicated.  The  charge  of  in- 
jury does  not  justly  lie  against  the  nature  of  the  remedy,  but  against  its  too 
great  strength.  We  do  not  hesitate  to  believe  that  all  the  evils  have  accrued, 
that  Dr.  C.  dreads;  indeed  we  have  seen  them,  yet  it  has  constantly  been  owing, 
agreeably  to  our  own  experience,  to  the  injudicious  use  and  the  inappropriate 
strength  of  the  solution,  that  caused  the  injuries  just  named. 


GONORRH(EA.  665 

mucous  membrane  of  the  urethra  to  be  in  a  state  of  high  inflam- 
mation. Injections  must  not  be  employed  in  this  stage,  the  in- 
dications being  exclusively  to  reduce  inflammation  as  quickly 
and  as  certainly  as  possible.  For  this  purpose,  the  patient  should 
be  confined  to  his  bed  for  a  few  days,  if  practicable ;  he  should 
be  liberally  purged,  and  the  strictest  antiphlogistic  regimen 
should  be  observed.  We  believe  that  the  neutral  salts  are  as 
eligible  as  any  of  the  purgatives,  and  these  should  be  repeated  as 
may  become  necessary.  Dr.  Carmichael  warmly  recommends 
the  tartrite  of  antimony  to  be  joined  to  the  Epsom  salts,  or  sul- 
phate of  magnesia,  and  administered  so  as  to  excite  slight  nausea, 
and  to  procure  four  or  five  stools  a  day.  He  should  take  most 
liberally  any  of  the  demulcent  drinks,  such  as  gum  Arabic  wa- 
ter, flaxseed  tea,  slippery-elm  bark  tea,  barley  water,  &c.  Leeches 
should  be  applied  to  the  perinaeum  when  this  is  the  seat  of  pain; 
and  when  the  chordee  is  excessive,  even  along  the  urethra.  By 
these  means,  the  inflammation  becomes  milder,  the  pain  abates, 
the  discharge  becomes  thinner  and  of  a  less  virulent  appearance; 
the  chordee  is  more  moderate,  and  is  less  frequent,  and  the  ex- 
tremity of  the  glans  loses  its  intense  redness  and  transparency—- 
in a  word,  the  patient  becomes  assured  the  disease  is  upon  the 
decline. 

c.  Us  Decline. 

3131.  When  this  condition  arrives,  the  gently  stimulating  in- 
jection just  stated  above  may  now  be  had  recourse  to  with  mark- 
ed advantage.     And  it  is  at  this  period  that  the  balsam  copaiva 
and  cubebs  become  serviceable,  and  should  always  be  given  when 
the  discharge  does  not  yield  to  the  injections.  When  the  balsam 
copaiva  or  eubeb  has  been  decided  upon,  we  have  thought  it  best 
to  suspend  for  a  time  the  use  of  the  acetate  of  zinc. 

3132.  The  balsam  very  frequently  excites  a  great  disgust  from 
its  strong  aromatic  taste.     This  is  chiefly  owing  to  the  mode  of 
exhibition,  being  usually  mixed  with  some  other  substance  which 
renders  its  taste  almost  insupportable — this  inconvenience  can 
be  readily  removed  by  the  following  plan.     Mix  a  tea-spoonful 
of  the  tinct.  amara  with  a  wine-glass  of  cold  water — in  this,  drop 
the  appropriate  quantity  of  the  balsam  ;  but  be  careful  not  to  mix 
them.   The  balsam  will  collect  itself  into  a  round  form,  and  will 
remain,  if  not  disturbed,  separate  from  the  bitter  tincture  and 
water.     When  thus  disposed  of,  let  the  whole  be  thrown  to  the 
back  part  of  the  mouth  and  swallowed ;  and  if  this  be  adroitly 
done,  the  balsam  will  impart  no  taste  to  the  palate.     Thirty  or 
forty  drops  of  the  balsam  may  be  taken,  three  times  a  day.     A 

84 


666  GONORRHOEA. 

drachm  of  powdered  cubebs*  may  be  taken  three  or  four  times  a 
day,  mixed  in  syrup  of  any  kind. 

3133.  Some  recommend  much  larger  doses  than  we  direct  of 
the  balsam  copaiva,  but  we  fear  upon  no  good  practical  grounds, 
as  it  rarely  happens  that  the  inflammation  of  the  urethra,  or  of 
the  neck  of  the  bladder,  is  so  entirely  subdued,  that  it  would  be 
either  safe  or  successful  to  follow  the  advice.    The  same  may  be 
said  of  the  cubebs. 

3134.  2.  In  the  treatment  of  gonorrhoea,  much  of  the  success 
will  also  depend  upon  the  appropriate  strength  of  the  remedies. 
They  are  generally  made  too  strong ;  and  an  overweaning  anxiety 
cause  them  to  be  used  too  frequently.     The  proportions  above 
mentioned  should  rarely  be  exceeded. 

3135.  3.  It  is  also  a  matter  of  much  moment  to  the  cure  of 
this  disease,  that  the  constitution  should  be  sound  ;  and  especially, 
it  should  be  free  from  scrofulous  taint. 

3136.  4.  The  disease  is  often  of  extremely  difficult  manage- 
ment, also  in  habits  long  accustomed  to  the  too  free  use  of  ardent 
spirits — the   reason,   of  these   difficulties  will  readily  present 
themselves. 

3137.  In  females,  the  disease  is  to  be  combated  by  the  same 
means,  and  under  the  same  restrictions.     The  woman  should 
however  throw  up  injections  in  both  the  urethra  and  vagina — in 
this  operation,  she  should  be  carefully  instructed,  lest  she  do 
mischief  to  the  urethra,  or  only  inject  the  vagina. 

3138.  During  the  whole  progress  of  treatment,  the  utmost  at- 
tention should  be  paid  to  diet;  to  the  state  of  the  bowels;  and  to 
cleanliness,  especially  in  the  female. 

3139.  The  diet  should  consist  of  vegetable  and  farinaceous 
substances,  exclusively — not  a  particle  of  animal  substance  should 
be  employed,  during  the  whole  of  the  first  and  second  stages— if 
any  latitude  be  allowed,  it  must  be  in  the  latter;  but  even  here,  it 
would  be  well  to  avoid  it.     The  bowels  should  be  kept  freely 
open,  by  almost  any  purgative  medicine  ;  and  none  answer  bet- 
ter, as  we  said  just  now,  than  the  neutral  salts.    Cleanliness  can- 
not be  too  much  insisted  on — frequent  ablutions  with  lukewarm 
flaxseed  tea,  where  this  would   not  be  inconvenient,  or  of  plain 
warm  water. 

3140.  No  one  circumstance  attendant  upon  this  disease,  is  so 
vexatious  as  chordee — it  often  prevents  sleep,  from  the  frequent, 

•  Mr.  Jefferiesis  of  opinion,  that  when  cubebs  .ire  successful,  signs  of  amend- 
ment show  themselves  as  soon  as  forty-eight  hours  after  they  have  been  com- 
menced; and  if  they  do  not  exert  a  favourable  influence  in  five  or  six  days,  it  is 
scarcely  worth  while  to  persevere  in  their  use.  He  says  this  remedy  should  be 
used  in  large  doses — that  is,  six  or  eight  drachms  of  cubebs  must  be  given  in 
the  twenty-four  hours,  but  after  active  inflammation  is  much  reduced. 


GONORRHOEA.  667 

and  long-continued  erections  that  almost  constantly  occur  during 
the  night.  Camphor,  opium,  and  cold  water,  are  the  general 
remedies  for  this  distressing  accompaniment.  The  \varm  bath 
has  been  found  useful  when  taken  just  before  going  to  bed.  The 
dulcamara? 

3141.  Ten  grains  of  camphor  may  be  taken  in  a  little  syrup 
of  any  kind  on  going  to  bed.     A  grain  or  a  grain  and  a  half  of 
opium  may  be  employed  for  the  same  purpose;  or  these  may  be 
united,  if  the  affection  be  very  pertinacious.     Or  the  penis  may 
be  subjected  to  a  stream  of  cold  water.     I  have  mentioned  the 
dulcamara  as  a  remedy  for  chordee;  but  of  its  efficacy  I  have  no 
proof;  but  from  analogy  I  would  employ  it.     I  have  used  this 
plant  in  infusion,  (an  ounce  to  a  pint  of  boiling  water,  and  this 
quantity  taken  daily,)  in  several  cases  of  high  constitutional  vene- 
real excitement,  (in  one  instance  amounting  to  furor  uteri n us,)  and 
to  several  gentlemen  for  cutaneous  affections,  in  each  of  whom, 
the  venereal  appetite  was  entirely  destroyed  as  long  as  this  medi- 
cine was  continued — it  would  therefore  seem  to  bid  fair  to  be 
useful,  in  chordee. 

Gleet. 

3142.  A  gleet  is  a  discharge  of  puriform  matter  from  the  ure- 
thra of  the  male,  after  all  infectious«taint  has  ceased  to  be  formed; 
in  the  female  it  is  almost  always  from  the  vagina,  and  generally 
passes  for,  or  is  called  fluor  albus,  or  leucorrhoea.    The  habit  of 
this  discharge  is  sometimes  very  difficult  to  break — hence  its 
continuance  for  years  in  very  many  instances. 

3143.  The  terebinthinate  medicines  have  long  held  a  conspi- 
cuous place,  in  the  treatment  of  this  affection,  and  they  always 
deserve  a  trial,  if  it  resist  the  appropriate  local  remedies.  For  the 
most  part,  especially  in  the  less  inveterate  cases,  these  are  every 
way  sufficient  to  put  a  stop  to  this  discharge — one  of  the  best  is 
the  sulphate  or  acetate  of  zinc.  Two  grains  to  the  ounce  of  water 
will  be  found  sufficiently  strong  for  the  purpose  provided  the 
urethra  is  free  from  stricture ;  this  may  be  injected  three  times  a 
day,  and  as  a  general  rule,  not  oftener.     Sulphate  of  copper  one 
grain  to  the  ounce,  and  increased  if  necessary  to  two  is  also  very 
useful.    The  nitrate  of  silver  has  also  been  recommended  in  high 
terms ;  it  should  not  exceed  two  grains  to  the  ounce.    There  con- 
stantly attends  however,  the  use  of  the  solution  of  this  article,  a 
very  serious  objection  ;  namely,  the  indelible  stain  it  leaves  upon 
every  substance  it  touches;  great  care  is  therefore  required  to 
guard  against  this  inconvenience.  Mr.  John  Hunter  recommends 
a  very  weak  solution  of  the  corrosive  sublimate,  (one  grain  to 
eight  ounces  ofc  water.)     Mr.  Foot  extols  the  following  prepara- 


668  DROPSY. 

tion  as  an  injection,  after  an  assurance,  that  all  inflammation  has 
subsided.  Dissolve  a  quantity  of  the  sulphate  of  copper  in  a 
quantity  of  water ;  precipitate  the  copper  by  the  lixivium  of  tar- 
tar ;  let  it  separate,  and  then  pour  off  the  clear  liquor.  The  pre- 
cipitate must  be  washed,  until  the  water  is  insipid ;  make  a  satu- 
rated solution  of  the  carbonate  of  ammonia  in  water,  filter,  and 
add  as  much  of  the  precipitate  to  the  solution  as  it  will  dissolve, 
which  set  by  for  use.  When  to  be  used,  add  six  drops  of  this 
preparation  to  an  ounce  of  water,  and  use  it  as  an  injection.  Of 
the  utility  of  this  ammoniated  copper  we  can  say  nothing  from 
our  own  experience. 

3144.  Beside  the  internal  use  of  the  balsam  copaiva,  and  the 
turpentine,  much  advantage  is  frequently  derived  from  a  perse- 
vering use  of  the  tincture  of  cantharides.  When  this  preparation 
is  decided  upon,  thirty  drops  should  be  given  three  times  a  day 
in  a  little  sweetened  water,  and  the  dose  increased  by  five  drops 
every  fourth  or  fifth  day,  until  some  irritation  is  felt  at  the  neck 
of  the  bladder — it  must  then  be  desisted  from  until  this  symptom 
goes  off.     The  medicine  must  now  be  commenced  de  novo  with 
the  minimum  dose,  and  gradually  increased  as  before,  provided 
the  disease  has  not  yielded  to  the  previous  quantity. 

3145.  When  gleet  resists  these  appliances,  there  is  much  rea- 
son to  suspect  a  stricture  in  the  urethra,  for  which,  the  bougie  is 
the  remedy. 


CHAPTER  XIII. 

DROPSY. 

3146.  WE  shall  not  stop  to  inquire  into  the  strict  nosological 
situation  of  dropsy,  as  it  would  seem  entitled,  with  about  equal 
right,  to  be  classed  among  the  affections  of  the  sanguiferous,  as 
with  the  derangements  of  the  absorbent  systems. 

3147.  By  dropsy  is  to  be  understood  a  preternatural  accumu- 
lation, most  frequently  of  a  serous  fluid,  in  one  or  more  cavities 
of  the  body,  or  in  its  cellular  interstices. 

3148.  The  part  of  the  body  in  which  this  collection  may  take 
place,  gives  a  specific  name  to  each  accumulation.     Thus,  when 
it  occupies  the  abdomen,  it  is  called  ascites ;  when  the  chest, 
hydrothorax,  &c.     But  as  the  pathology  of  each  variety  seems 
to  be  very  much  the  same  in  most  instances,  we  shall  say  a  few 
words  in  relation  to  its  proximate  cause.    By  this,  however,  we 


DROPSY.  669 

are  not  to  be  understood  as  attempting  to  settle  this  still  disputed 
point. 

3-149.  It  is  ascertained,  that  in  health  a  constant  balance  is 
maintained  by  two  opposite  and  extensive  functions  in  the  body, 
namely,  exhalation  and  absorption ;  and  that  when  this  equili- 
brium is  destroyed,  either  by  an  excess  of  exhalation  or  a  dimi- 
nished absorption,  an  accumulation  must  necessarily  take  place, 
and  hence  dropsical  swellings.  For  the  structure  of  the  cellular 
tissue  is  such,  as  to  leave  spaces  or  meshes  throughout  its  whole 
distribution,  and  that  these  spaces  *or  meshes  contain  a  fluid, 
which  has  been  called  by  Bichat  cellular  serosity.  But  we  have 
every  reason  to  believe,  that  in  a  normal  condition  of  the  cellu- 
lar structure,  it  contains  nothing  but  a  thin  exhalation  or  va- 
pour— or  in  other  words,  that  in  the  Irring  body  the  cellular 
membrane  contains  no  distinct  fluid  beyond  the  elastic  one  just 
spoken  of,  and  which  appears  every  way  sufficient  for  the  pur- 
poses for  which  it  is  designed,  namely,  to  give  it  suppleness. 
This  fluid  or  vapour,  agreeably  to  all  confession,  would  seem  to 
be  derived  from  the  capillary  exhalants,  and  is  very  quickly  after 
its  elimination  removed  by  absorption — but  whether  this  action 
be  performed  by  the  lymphatics  as  supposed  by  Hunter,  or  by  the 
radicles  of  veins,  as  insisted  on  by  Magendie,  or  by  both,  remains 
yet  to  be  determined.  But  this  is  not  of  any  moment  in  our  pre- 
sent inquiry,  for  by  whatever  agency  this  is  effected,  we  know 
it  constantly  goes  on  in  the  healthy  condition  of  the  body,  and 
thus  accumulation  is  prevented.* 

*  The  origin  of  this  exhalation  or  vapour,  which  is  every  where  found  in  the 
cellular  interstices,  is  rather  a  disputed  point  among  physiologists,  as  the  ves- 
sels purporting  to  perform  this  office,  namely,  the  exhalants,  agreeably  to 
some  have^a  disputed  existence.  Bichat  admitted  them,  (that  is,  a  certain  set 
of  minute  arteries,  the  open  extremities  of  which  pour  out  a  fluid,)  rather  by  a 
rigorous  process  of  reasoning,  than  from  anatomical  demonstration;  Magendie 
and  Beclard  deny  the  existence  of  such  a  system  of  vessels,  though  they  admit 
exhalation  to  be  a  process  of  the  living  body.  And  it  is  now  generally  supposed 
that  the  capillaries  perform  this  office,  and  without  the  necessity  of  having  re- 
course to  the  speculation  of  a  distinct  set  of  vessels.  But  let  the  mechanism 
ihat  furnish  exhalations  be  what  it  may,  it  is  every  way  certain,  they  "  may  be 
morbidly  augmented  or  diminished,  or  quite  changed."  The  best  examples 
of  morbid  increase  of  exhalation  is  conceived  to  be  found  in  those  of  the  serous 
membranes,  giving  rise  to  the  disease  called  dropsy.  (~Hydrops.J)  It  is  most 
frequent  in  the  peritoneum,  and  in  the  general  cellular  membrane;  less  so  in 
the  pleura  and  pericardium,  and  in  the  arachnoid  membrane,  or  its  divisions. 
In  a  local  form  it  is  very  frequent  in  the  vaginal  coat  of  the  testicle.  Recent 
observations  on  this  morbid  change,  and  on  the  state  of  the  system  when  under 
its  influence,  would  lead  to  the  conclusion,  that  it  is  rarely  a  primary  process, 
but  is  generally  to  be  considered  as  the  effect  of  another, — as  the  symptom  of 
a  peculiar  condition  of  the  system  of  capillary  arteries  going  to  the  tissue  which 
is  the  immediate  seat  of  exhalation." 

"  The  condition  of  the  capillary  system  in  which  exhalation  is  preternatu- 
rally  augmented  are  referable  to  two  general  heads.     The  first  of  these  is  the 


670  DROPSY. 

3150.  This,  however,. notwithstanding  its  simplicity  and  its 
apparent  verity,  is  not  found  to  be  the  true  explanation,  except 
perhaps  in  some  few  instances,  to  be  noticed  presently.  For, 
1st.  The  fluid  constituting  dropsy  is  not  always  found  to  be 
the  healthful  yield  of  the  exhalants.  2d.  That  absorption 
is  scarcely  ever  more  rapid  or  vigorous,  than  in  dropsy,  as 
is  evidenced  by  the  sudden  emaciation  that  follows  ;  consequent- 
ly, in  such  cases,  absorption  goes  on  rapidly.  Therefore  it  would 
seem,  that  this  disease  does  not  always  depend  upon  an  increase 
of  exhalation,  or  upon  a  diminution  of  absorption.  To  what  cir- 
cumstance, then,  are  we  to  attribute  dropsical  collections  ?  We 
would  say,  to  a  morbid  increase  of  activity  in  the  blood-vessels, 
which  enter  into  the  composition  of  the  serous  tissue,  and  thus 
forcing  this  membrane  to  a  preternatural  effusion  or  secretion. 

state  of  distention  which  results  from  any  mechanical  impediment  to  the  free 
motion  of  the  blood  in  a  venous  trunk  or  trunks,  or  in  the  arteries." 

"  a.  That  the  distended  or  overloaded  state  of  the  capillaries  which  occurs 
during  inflammation  may  cause  a  great  and  disproportionate  increase  of  the 
fluid  exhaled,  is  established  by  the  phenomena  of  inflammation  of  the  fila- 
mentous (cellular)  tissue,  and  especially  of  the  serous  membranes.  In  the 
former,  oedema  and  anasarca  are  results  by  no  means  unfrequent.  In  the  latter, 
one  of  the  first  effects  of  inflammation,  under  certain  circumstances,  is  effusion 
of  fluid  more  or  less  copious,  and  containing  various  proportions  of  coagulable 
matter.  If  the  proportion  of  the  latter  be  great,  its  coagulation  forms  organiza- 
ble  lymph,  which  is  the  medium  of  adhesion,  while  the  serous  part  disappears, 
apparently  by  absorption.  If  it  be  small,  its  coagulation  gives  rise  to  mere 
loose  flakes,  which,  with  the  constant  increase  of  the  fluid  effused,  are  unable 
to  maintain  their  attachment  to  any  part  of  the  membrane;  while  the  thin  se- 
rous part  is  so  copious,  that,  as  it  is  not  removed  by  the  veins  and  lymphatics, 
it  remains  in  the  form  of  a  serous,  a  sero-sanguine,  or  a  sero- purulent  fluid,  con- 
stituting genuine  dropsy." 

"  That  the  capillary  distention  which  takes  place  in  fever  is  a  frequent  cause 
of  anormal  exhalation,  is  shown  by  the  collections  of  limpid  serum  often  found 
in  the  brain  and  spinal  cord;  by  that  sometimes  seen  in  the  pericardium;  and 
by  the  brownish  watery  fluid  often  found  in  the  pleura  in  the  bodies  of  those 
cut  off  by  any  of  the  varieties  of  that  disease." 

ftb.  The  influence  of  impediment  to  the  return  of  the  venous  blood  in  the 
production  of  extraordinary  effusion  has  been  known  from  the  earliest  periods 
of  medicine."  "The  fact  is  established  by  the  effects  of  deranged  circulation, 
as  they  take  place,  first,  in  veins;  secondly,  in  arteries;  and  thirdly,  in  both  sets 
of  vessels  jointly,  or  in  the  capillaries." 

"  To  the  first  head  may  be  referred  tumours  in  the  vicinity,  or  affecting  the 
substance  of  veins;"  "of  the  influence  of  the  second  cause  in  producing  drop- 
sical effusion,  we  have  examples  in  that  which  results  from  enlargement  of  the 
right  side  of  the  heart,  ossification  of  the  coronary  arteries,  aneurism  of  the 
aorta  or  innominata,  or  even  of  the  coeliac  artery,  all  of  which  give  rise  to  more 
or  less  serous  effusion  in  the  pleura,  or  a  symptomatic  dropsy  of  the  chest." 

"  The  third  condition  is  perhaps  the  most  common  origin  of  the  symptoma- 
tic or  secondary  dropsies.  Whatever  retards  the  free  circulation  through  the 
minute  arteries  and  veins  of  any  organ  or  texture  will  produce  one  or  other  of 
the  following  effects;  viz.  inflammation,  injection  with  effusion  of  red  blood, 
or  effusion  of  serous  fluid  from  the  exhalants,  according  to  circumstances." — 
Elements  of  General  and  Pathological  Anatomy,  by  David  Craigie,  M.  D.  p.  201. 


DROPSY.  671 

Here,  then,  we  have  a  natural  action,  morbidly  increased,  as  the 
proximate  cause,  and  an  increased  effusion  as  the  proximate  ef- 
fect of  that  cause — and  hence  watery  or  serous  accumulation  in 
cavities  thus  circumstanced.  When  this  accumulation  takes 
place,  we  can  readily  imagine  that  it  may  be  perpetuated,  if  not 
augmented,  by  the  effused  fluid  itself  becoming  a  mechanical 
stimulus  to  the  surface  with  which  it  is  in  contact.  And  what 
seems  to  prove  the  presence  of  a  morbid  excitement  is,  that  the 
removal  of  the  water,  either  by  medicine  or  by  an  operation, 
does  not  always  cure  the  disease — for  it  requires  for  this  purpose 
a  change  in  the  action  of  the  vessels  that  furnish  this  fluid,  and 
not  its  mere  removal.  Hence,  its  removal  by  an  augmented  ab- 
sorption, or  by  tapping,  do  not  always  succeed,  because  they  do 
not  necessarily  remove  or  controul  the  local  diseased  action.  And 
hence,  the  confusion  so  often  found  to  exist  in  the  pathology  of 
dropsy,  arises  from  mistaking  the  effect  for  the  cause. 

3151.  It  may  be  said  that  the  serous  membranes  may  be  in- 
flamed and  relieved  without  yielding  a  dropsical  effusion.     But 
this,  however,  must  be  admitted  with  some  caution,  since  Laen- 
nec  lays  it  down  as  a  fundamental  law  of  this  class  of  membranes, 
that  they  begin  to  effuse  the  moment  they  become  inflamed;  nor 
is  it  essential  to  this  end,  that  the  phlogosis  shall  be  even  consi- 
derable in  all  cases.  Or  in  other  words,  that  effusions  have  taken 
place  in  a  serous  membrane,  especially  in  that  of  the  pleura, 
without  any  great  manifestations  of  the  existence  of  inflamma- 
tion; at  least  as  far  as  could  be  detected  by  local  symptoms.     In- 
deed, it  would  seem  to  be  a  part  of  the  oeconomy  of  these  mem- 
branes, to  effuse  abundantly,  when  but  slightly  inflamed;  for  in- 
stance, the  arachnoid  coat  of  the  brain.     Or,  these  membranes 
may  be  stimulated  to  profuse  secretion,  independently  of  inflam- 
mation, or  even  after  this  has  ceased — hence,  perhaps,  the  variety 
of  colours  observed  in  the  fluid  of  dropsies.     As  regards  the  co- 
lour of  the  fluid  of  dropsies,  Dr.  Armstrong  says,  "  when  the 
fluid  drawn  from  the  abdomen  of  dropsical  patients  is  turbid  from 
the  presence  of  albumen  or  fibrine,  which  is  easily  ascertainable, 
the  case  is  connected  with  inflammation  of  some  portion  of  the 
peritoneum  ;  but  when  the  fluid  evacuated  is  perfectly  transpa- 
rent and  straw-coloured,  it  affords  a  strong  presumption,  that 
some  great  organic  affection  exists  in  the  liver,  or  else  where. " — 
Morbid  Anatomy,  fyc.  p.  76. 

3152.  It  may,  however,   be  urged,  that  there  are  cases  of 
dropsy  or  of  oedema,  in  constitutions  so  enfeebled  as  to  forbid 
the  idea  of  inflammatory  agency — this  really  appears  to  be  the 
case  in  certain  instances,  as  in  chronic,  wasting  diseases;  such  as 
scrofula,  phthisis  pulmonalis,  chronic  peritonitis,  &c.     In  such 
cases,  we  should  be  disposed  to  believe,  that  accumulations  of 


672  DROPSY. 

serum  from  diminished  absorption  really  takes  place,  and  this 
perhaps  from  the  generally  deranged  state  of  the  lymphatic  sys- 
tem in  most  of  these  diseases.  This  is  rendered  still  more  pro- 
bable by  our  having  it  in  our  power  frequently  to  remove  these 
swellings  temporarily  by  position,  frictions,  and  bandaging. 

3153.  By  this,  we  are  not  to  be  supposed  to  yield  to  a  once 
popular  opinion,  that  dropsy  was  essentially  a  disease  of  debility — 
on  the  contrary,  we  are  certain,  that  there  are  both  active  and 
passive  dropsies;  or  rather  dropsies  that  depend  upon  an  increase 
of  action  or  of  inflammation,  and  others  where  there  may  be  a 
mere  loss  of  balance  between  exhalation  and  absorption.  *  We  are 
aware  of  the  tendency  of  all  doctrines  to  run  into  extremes;  and 
lucky  is  he  who  can  determine  how  far  to  pursue  them  with  ad- 
vantage, or  to  perceive  when  it  is  proper  to  stop.  For  we  are 
persuaded,  that  if  either  of  the  doctrines  mentioned  above  be 
too  exclusively  acted  upon,  that  disappointment,  if  not  injury, 
will  follow.  And  it  would  be  fortunate  for  the  profession,  as 
well  as  highly  important  to  the  cause  of  humanity,  were  we  in 
possession  of  certain  and  never-failing  diagnostics,  of  the  two 
conditions  of  the  system. 

*  "  No  doubt  what  we  abstractedly  call  dropsy,  is  often  the  result  of  inflam- 
mation, and  much  good  has  arisen  by  attempts  to  refer  dropsy,  a  mere  conse- 
quence, to  its  true  causes;  but  the  doctrine  of  inflammation  is  unquestionably 
carried  too  far  when  it  is  made  to  embrace  every  modification  of  dropsical  dis- 
ease, which  in  the  aged  is  so  frequently  occasioned  by  organic  derangement, 
of  a  most  dangerous  kind,  that  we  might  apply  to  them  the  language  of  Are- 
tacus,  ab  ipso  pauci  liberantur,  idque  felicitate,  acdeorum  potius  quam  artis  aux- 
illio.  If  however,  I  might  digress  for  a  moment,  one  variety  of  inflammation, 
namely,  that  of  the  inner  lining  of  the  arteries  and  veins,  is  oftener  connected 
with  dropsy,  than  even  most  of  the  advocates  of  the  phlogistic  hypothesis  are 
aware;  at  least  I  have  so  frequently  witnessed  it,  that,  in  every  fatal  case  of 
dropsy  I  would  advise  an  examination  of  those  vessels,  that  we  may  thereby 
be  able  more  fully  to  elucidate  this  point  of  pathology." — Armstrong,  ib.  This 
is  a  new  and  highly  interesting  suggestion,  and  well  deserves  the  attention  of 
the  cultivators  of  morbid  anatomy.  The  medical  world  is  indebted  to  Dr.  Rush, 
for  most  of  the  opinions  now  entertained  of  dropsy. 

Andral  thinks,  that  the  serous  membranes  may  become  congested  from  a  ge- 
neral hypercemia  or  plethora  of  the  system;  and  when  this  happens  that  serous 
effusions  unattended  by  pain  may  take  place  into  the  different  cavities  lined 
with  serous  membranes,  especially  the  abdomen.  He  adds,  "  it  appears  to  me 
highly  probable  that  these  dropsical  effusions  which  are  generally  denominated 
active,  are  simply  the  mechanical  result  of  the  over-distention  of  the  vessels, 
which  allow  the  serous  portion  of  the  fluid  to  transude  through  the  parietes  of 
their  capillary  ramifications.  In  confirmation  of  this  view  of  the  subject,  I  may 
cite  the  observation,  that  if  a  large  quantity  of  water  be  injected  into  the  veins 
of  an  animal,  without  having  first  withdrawn  blood  from  the  system,  serous  ef- 
fusions are  quickly  formed;  whereas,  if  the  mass  of  blood  be  diminished  by  ve- 
nesection before  the  water  is  injected,  that  fluid  is  gradually  and  almost  im- 
perceptibly eliminated.  Besides  we  know  from  actual  experience,  that  those 
dropsies  usually  termed  active,  which  are  combined  with  a  state  of  general  hy- 
percemia  of  the  system,  are  constantly  relieved,  and  not  unfrequently  altogether 
removed,  by  the  use  of  the  lancet." — Pathological  -Anatomy,  Vol.  I.  p.  46. 


HYDROCEPHALUS    INTERNUS.  673 

3154.  It  is  true  that  attempts  have  been  lately  made  to  deter- 
mine the  signs  of  the  respective  states  of  dropsy,  by  Dr.  Black- 
all,  and  we  are  disposed  to  believe  he  has  succeeded  in  removing 
some  of  the  difficulties  upon  this  subject,  if  he  have  not  overcome 
them.     He  states  that,  in  dropsies  of  high  excitement,  that  the 
urine  will  always  coagulate  by  heat  or  nitrous  acid,  like  the  se- 
rum of  the  blood.     While  dropsies  proceeding  from  visceral  de- 
rangements, as  scirrhus  or  congestion,  may  be  known  by  the 
urine  being  scanty,  high-coloured,  loaded  with  red  sediment,  and 
depositing  nothing  on  the  application  of  heat.   And  where  feeble 
action  obtains,  the  urine  is  scanty  and  pale,  and  not  coagulable 
by  heat,  and  deposits  no  sediment. 

3155.  We    have    been    attentive,  since  we  have    read  Dr. 
Blackall's  book,  to  the  appearances  of  the  urine ;  and  though  ge- 
nerally confirmatory  of  his  distinctions,  our  experience  does  not 
always  coincide  with  them.* 

3156.  Dropsy,  as  we  have  observed  above,   (par.   3148,)  re- 
ceives a  specific  name,  from  the  part  of  the  body  in  which  the 
affection  may  be  located ;  or  from  the  organ   that  may  produce 
it.     As  ascites,  or  abdominal  dropsy  ;  ovarian  dropsy ;  hydroce- 
phalus,  &c.     Some  dropsies  do  not  belong  to  the  physician, 
strictly  so  called  ;  as  hydrocele,  and  we  might,  with   equal  pro- 
priety add,  the  dropsy  of  the  ovarium,  as  relief  is  but  rarely  ob- 
tained, by  constitutional  remedies. 

SECT.  I. — HYDROCEPHALUS  INTERNUS. 

3157.  It  does  not  appear  to  be  of  much  consequence  in  a  prac- 
tical point  of  view,  the  place  we  give  hydrocephalus  internus; 
nor  do  we  look  upon  it  as  a  matter  of  moment  as  a  nosological 
arrangement;  for  two  places  perhaps  may  with  equal  propriety 
be  assigned  it — first,  either  immediately  following  the  acute  affec- 
tions of  the  brain;  or  second,  ranking  it  with  dropsy.     And  as 
we  do  not  profess  to  be  attentive  to  any  strict  nosological  clas- 
sification, we  give  it  the  place  it  is  now  found  in  ;  and  more  es- 
pecially as  it  is  not  only  an  inflammatory  affection,  but  one  ex- 
clusively confined  to  the  head,  some  of  the  diseases  of  which, 
we  have  been  considering,  and  particularly  phrenitis,  to  which 
it  is  occasionally  without  doubt,  a  sequel. 

315S.  It  would  be  altogether  time  ill-spent,  in  a  work  like  the 
present,  to  inquire  into  the  medical  history  of  this  disease ;  we 

*  It  is  beyond  dispute,  that  dropsy  may  proceed  from  the  want  of  a  due 
quantity  of  blood.  Dr.  Gaspard,  (Jour,  de  Physiologic  Exper.)  says  that  the 
inhabitants  of  a  certain  country  became  dropsical  on  account  of  their  being 
obliged  to  live  upon  grass  for  a  considerable  time,  in  consequence  of  a  devas- 
tating famine. 

85 


674  HYDROCEPHALTJS    INTEBNUS. 

refer  those  who  are  curious  upon  this  point,  to  the  works  that 
treat  professedly  upon  this  subject.  We  shall  only  observe,  that 
however  familiar  the  ancients  might  be  supposed  to  have  been 
with  hydrocephalus  internus,  it  is  every  way  certain,  that  its  pa- 
thology was  perhaps  altogether  unknown  to  them  ;  for  it  is  only 
within  a  very  few  years,  that  it  has  be.en  well  understood  even 
by, the  moderns. 

3159.  By  hydrocephalus  internus,  is  to  be  understood  a  pre- 
ternatural turgescency  of  the  vessels  of  the  brain ;  a  collection  of 
serum,  or  serosity,  within  the  ventricles,  or  upon  the  surface  of 
the  brain,  or  all ;  for  dissection  has  discovered  to  us,  that  each  of 
these  circumstances  may  obtain  at  one  and  the  same  time. 

3160.  Mr.  Itard*  with  much  propriety,  and  we  think  also 
with  much  pathological  truth,  makes  four  species  of  this  disease. 
1st  Acute,  idiopathic  hydrocephalus.    2d.  Acute,  symptomatic 
hydrocephalus.     3d.   Chronic  idiopathic  hydrocephalus.     4th. 
Chronic  symptomatic  hydrocephalus. 

3161.  The  first  species,  is  made  to  consist  of  serum  suddenly 
effused  by  the  tunica  arachnoides,  in  consequence  of  an  idiopa- 
thic affection,  within  the  ventricles,  and  upon  the  surface  of  the 
brain  itself.     This  may  be  occasioned  by  external  violence,  as 
falls,  and  blows ;  or  by  sudden  passions  or  emotions  of  the  mind, 
as  anger,  fear,  frights,  &c.  by  the  sudden  arrest  of  habitual  eva- 
cuations, as  bleeding  from  the  nose,  the  discharge  from  crusta 
lactea,  sore  ears;  or  the  drying  up  of  issues.   It  is  most  common 
with  children ;  and  particularly  between  the  periods  of  the  first 
and  second  dentition,  among  those  of  a  robust  constitution,  and 
of  florid  complexions — at  other  times,  it  appears  to  be  constitu- 
tional, and  to  run  in  families.   We  are  at  this  moment  attending 
a  little  girl  of  nine  months  old,  with  this  species  of  complaint, 
who  has  lost,  we  are  informed  by  the  parents,  five  brothers  and 
sisters  of  the  same  disease;  and  Cheyne  mentions  a  much  more 
numerous  loss  of  this  kind.     In  adults  it  is  rare ;  yet  with  them, 
we  have  seen  it  in  several  instances  prove  fatal.     Agreeably  to 
Itard,  epidemic  peculiarity  has  an  influence  upon  its  prevalence. 
In  one  instance,  an  epidemic  scarlatina;  and  in  another,  an  ataxic 
fever,  were  followed  by  many  cases  of  hydrocephalus.t 

3162.  The  proximate  cause  of  this  disease  appears  to  consist  of 
an  irritation  or  inflammation  of  the  tunica  arachnoides,  which 
eventuates  in  an  effusion  of  serum  from  such  portions  of  this 
membrane,  as  may  be  subject  to  this  irritation  or  inflammation; 

•  Diet,  des  Sciences  Med.  Art.  Hydrocephale. 

f  Duges  is  of  opinion,  that  the  acute  hydrocephalus  may  be  produced  by 
any  cause  that  operates  violently  upon  the  nervous  system;  especially,  jealousy 
and  terror. 


HYDROCEPHALUS   INTERNUS.        ,  675 

and  which  consequently  may  be,  any  portion  of  surface  of  the 
encephalon  which  this  membrane  covers.  If  this  be  true,  it 
must  be  evident,  that  we  must  have  at  least  three  periods  in  the 
disease;  each  of  which,  during  its  continuance,  must  necessarily 
have  its  own  characters. 

3163.  Dr.  Whytt,  many  years  ago,  divided  this  disease  into 
three  stages ;  but  certainly  without  understanding  its  pathology. 
He  has  however  notwithstanding  this,  proved  himself  to  be  a 
very  accurate  observer,  and  a  faithful  recorder  of  symptoms ;  for 
we  very  much  doubt,  whether  a  more  accurate,  general  history 
could  be  given,  especially  of  chronic  hydrocephalus  than  he  has 
left  us.     He  certainly  was  unacquainted  with  the  two  states  of 
inflammation  now  so  generally  acknowledged,  as  well,  as  so  com- 
monly acted  upon  ;  though  he  has  given  evidence,  that  hydroce- 
phalus may  be  symptomatic;  for  in  enumerating  the  causes,  he 
mentions,  "ischuria,"  as  giving  rise  to  this  complaint;  and  that 
"  in  tedious  chronic  diseases,  water  is  often  collected  in  the  ven- 
tricles of  the  brain."* 

3164.  The  first  period  of  the  acute  hydrocephalus,  is  generally 
marked  by  a  more  than  usual  reluctance  in  the  child  to  talk ; 
seeking  the  darker  places  of  the  room;  peevish  much  beyond  its 
usual  wont;  loss  of  appetite,  or  voraciousness;  pretty  sudden  loss 
of  strength;  an  unnatural  heat  of  skin,  especially  about  the  head, 
though  the  exposed  hands  may  be  even  cooler  than  natural ;  a 
contraction  of  the  forehead  and  eyebrows;  an  intolerance  of  light 
and  noise ;  a  frequent  pulse,  especially  towards  evening ;  a  flushed 
face,  or  only  one  cheek ;  heaviness  of  the  eyes,  and  sometimes  a 
discharge  of  water  from  them.     If  the  child  be  old  enough  to  be 
interrogated,  it  will  declare  its  head  to  be  the  seat  of  its  suffer-, 
ings;  if  it  be  not,  it  will  manifest  this,  by  vague,  and  ill-directed 
attempts  to  place  its  hand  upon  it.    These  actions,  especially  in 
children  under  two  years  of  age,  are  very  often  mistaken  in  what 
they  mean — thus  with  some,  attempts  are  made  to  put  their 
fingers  in  the  mouth,  especially  if  they  have  not  passed  the  first 
year;  with  others,  beyond  this  period,  the  nose  is  frequently 
rubbed ;   with  others,  rather  more  advanced,  the  nostrils  are 
picked,  even  to  bleeding ;  while  others,  still  younger,  will  roll 
their  heads  from  side  to  side  with  fatiguing  perseverance.     The 
former  of  these  symptoms  are  almost  always  attributed  to  worms; 
while  the  latter  always  produces  an  apprehension,  that  "the  head 
is  affected." 

3165.  The  child  for  the  most  part  is  rather  drowsy;  that  is,  it 
lies  with  its  eyes  closed,  and  appears  to  sleep — but  this  is  either 
merely  an  instinctive  act,  or  the  sensibility  of  the  child  is  inor- 

•  Works,  p.  740. 


676  HYDROCEPHALUS   INTERNUS. 

dinately  increased;  for  the  least  noise,  suddenly  made,  or  the 
slightest  touch,  will  excite  an  alarm,  that  is  manifested,  by  sud- 
den startings.  Or  it  will  utter,  during  sound  sleep,  apparently 
piercing  and  fearful  cries,  without  being  able  to  state,  that  it  was 
either  alarmed,  or  in  pain.  Sometimes  we  have  observed  the 
head  during  several  days  together,  carried  first  on  one  side  and 
then  on  the  other;  and  complaint  is  made  with  those  sufficiently 
old,  of  a  pain  in  the  back  of  the  neck.  The  secretion  of  the  nos- 
trils is  almost  always  stopped  altogether;  and  a  dry,  characteris- 
tic cough,  is  almost  certain  to  be  present,  and  almost  always  con- 
tinues through  the  whole  course  of  the  disease.  We  do  not 
recollect  an  instance  of  idiopathic  acute  hydrocephalus,  without 
this  cough  being  present* 

3166.  As  the  disease  advances,  and  is  about  to  form  the  second 
period,  we  find  an  aggravation  of  almost  all  the  symptoms;  the 
child  now  inclines  to  lie  constantly,  and  may  be  observed  to 
press  its  hind  head  forcibly  against  the  pillow  that  supports  it; 
or  is  much  inclined  to  lie  with  it  low.    If  it  be  raised,  the  head 
hangs  motionless  down,  and  the  child  betrays  much  uneasiness  at 
the  change  of  position ;  and  if  it  can  speak,  desires  to  be  laid  down 
with  an  importunity  and  impatience  that  loudly  proclaims  its  suf- 
ferings.  When  the  child  is  returned  to  its  pillow,  it  is  oftentimes 
pale,  and  apparently  much  exhausted  by  the  effort  it  has  made ; 
it  will  sigh  deeply,  or  scream  violently.  The  face  becomes  more 
flushed,  or  there  may  be  a  deep-red  spot  on  one  cheek  only,  which 
will  perhaps  in  the  course  of  a  few  minutes  shift  itself  to  the  other 
cheek.     The  lips  are  dry  and  parched;  the  tongue  for  the  most 
part  is  clean;  and  there  is  either  great  thirst,  or  no  demands  are 
made  for  drink.     The  pulse  now  becomes  slower  and  more  con- 
tracted; the  pupils  widen,  and  an  occasional  obliquity  in  the  eye 
may  be  observed;  the  forehead  becomes  permanently  corrugated 
and  the  eyebrows  contracted. 

3167.  The  mouth  is  kept  in  almost  constant  motion  ;  the  tongue 
is  frequently  thrust  beyond  the  lips,  and  again  suddenly  retract- 
ed ;  the  eyes  are  kept  almost  constantly  open,  if  the  room  be 
dark ;  but  if  a  strong  light  be  suddenly  admitted  to  them,  the 
pain  becomes  so  intense,  that  a  violent  scream  is  instantly  given, 
accompanied  by  an  earnest  desire  "to  take  the  frightful  thing 
away. '•*     We  have  seen  this  repeated  a  number  of  times  in  the 
same  individual ;  indeed,  for  a  time,  whenever  a  sudden  light 
was  admitted,  and  especially  the  light  of  a  candle,  when  it  was 
necessary  to  approach  one,  to  give  its  medicines,  or  for  other 

•  We  believe  that  Dr.  Physick  was  the  first  observer  of  this  symptom  being 
an  almost  constant  attendant  upon  this  disease,  as  we  do  not  find  it  named  in 
some  very  late  publications  upon  this  disease.  But  notwithstanding  this  silence, 
we  are  every  way  confirmed  in  the  frequency  and  truth  of  the  observation. 


HYDROCEPHALTJS   INTERMITS.  677 

purposes.  Indeed,  the  eye  may  almost  be  said  to  obtrude  itself 
upon  our  notice;  not  only  from  the  extreme  sensibility  it  mani- 
fests to  light  for  some  time,  but  from  the  varying  and  prophetic 
changes  it  undergoes  to  the  last  moment  of  life.  It  is  either 
steadfastly  fixed,  or  constantly  moving;  now  shrinking  from  the 
light,  from  exquisite  torture,  or  gazing  upon  the  broad  day,  with 
the  most  perfect  indifference.  Now  convulsively  drawn  upwards 
under  the  eyelid,  that  nothing  but  the  whites  can  be  seen,  even 
by  separating  the  palpebrae;  or  their  coloured  portions  sunk  deep 
in  the  inner  angles  of  the  orbits— no  visible  part  of  the  frame  ap- 
pears to  undergo  such  decided  changes  as  these  little  organs ;  nor 
from  the  condition  of  which,  can  so  much  be  learnt  by  the  atten- 
tive observer.  It  is  said,  that  a  convulsive  oscillation  of  the 
pupil  may  be  observed  upon  the  approach  of  light,  which  ap- 
pearance is  declared  to  be  peculiar  to  the  acute  hydrocephalus. 
Now  were  this  constant,  which  it  is  not,  though  so  declared  by 
M.  Itard,  it  might  be  highly  useful  in  diagnosis,  as  it  would  form 
a  pathognomonic  sign. 

3168.  The  bowels  are  for  the  most  part  constipated,  and  diffi- 
cult to  move;  the  epigastrium  more  or  less  tender,  and  the  abdo- 
men sunk ;  the  urine  scarce,  and  generally  high-coloured,  depo- 
siting a  white  mucilaginous  substance,  sometimes  with  shining 
particles  floating  in  it;  the  hands  and  feet  inclined  to  become 
cold,  while  sweat  may  be  observed  upon  the  forehead  and  about 
the  neck.  This  state  of  things  continue  for  an  uncertain  period, 
when  the  third  period  may  be  ushered  in  by  convulsion  or  by  a 
manifest  squinting,  with  decided  coma.  Paralysis  may  be  added 
to  the  new  symptoms,  or  a  pretty  constant  twitching  of  the  leg 
and  arm  of  the  same  side,*  or  a  regular  and  constant  motion  of 
them  may  be  now  kept  up ;  the  pulse  is  very  frequent,  small, 
and  wiry — the  face  disfigured  by  a  livid  suffusion;  a  cold  sweat 
bedews  the  whole  body;  the  breathing  becomes  slow,  and  ster- 
torous, until  death  closes  the  scene;  or  this  event  may  be  sadly 
hastened  by  convulsions.  The  bowels  during  this  period  reluc- 
tantly yield  a  dark,  rue-coloured  bile;  and  the  urine  oftentimes  is 
entirely  suppressed.  This  period  is  uncertain  in  its  duration;  it 
may  continue  several  days,  or  it  may  terminate  in  a  few  hours. 
Indeed,  we  have  seen  a  number  of  instances,  where  convulsion 
has  not  ceased,  for  a  moment,  for  seven  or  eight  hours  together. 
We  do  not  recollect  having  seen  a  single  instance  of  convulsions 
that  were  not  preceded  by  strabismus,  though  we  have  often  seen 
strabismus  without  convulsions. 

*  When  paralysis  attends  hydrocephalus,  it  always  declares  a  more  aggra- 
vated form  of  the  disease,  and  perhaps  proves  that  some  portion  of  the  cere- 
brum itself  is  involved  in  the  disease.  See  par.  837. 


678  HYDROCEPHALT7S    INTERNUS. 

3169.  The  duration  of  an  acute  hydrocephalus  is  very  uncer- 
tain, and  dependent  upon  circumstances  of  cause,  constitution, 
extent  of  effect,  and  the  period  of  life.     Nor  is  the  succession  of 
symptoms  less  variable;  each  individual  case  showing  its  own 
peculiarities.  Its  progress  will  therefore  be  sometimes  sufficiently 
rapid  and  severe  to  destroy  in  a  very  few  days;  and  other  times 
it  may  occupy  weeks  before  it  shall  terminate.     The  cases  in 
which  head-ache  has  been  severe,  and  where  squinting  takes 
place  early,  are  those  that  terminate  the  soonest.   Again,  if  after 
the  third  or  fourth  day,  the  child  looses  its  flesh  rapidly,  becomes 
very  pale,  and  its  features  suddenly  sink,  it  is  pretty  certain  that 
the  disease  will  run  its  course  rapidly.    At  other  times,  the  pro- 
gress is  slow,  and' without  much  violence  of  symptoms;  and  thus 
runs  into  a  chronic  form. 

3170.  There  is  a  peculiarity  in  the  character  of  this  disease, 
that  is  truly  distressing,  and  ever  to  be  dreaded;  because,  so  far 
as  we  have  observed,  it  is  always  deceitful — what  we  allude  to 
is,  the  promise  of  restoration,  by  apparently  a  real  amendment. 
We  have  seen  a  number  of  .cases,  where  almost  every  threaten- 
ing symptom  had  removed  itself;  and  where  the  little  patient, 
seemingly,  was  suddenly  placed  in  a  state  of  convalescence,  and 
hope  entertained  that  the  danger  was  past — but  in  another  in- 
stant every  thing  was  reversed,  and  the  child  quickly  destroyed, 
by  a  cruel  convulsion.     This  calm  was  probably  owing  to  the 
relief  the  vessels  experienced  from  the  act  of  effusion,  and  the 
subsequent  and  suddenly  bad  symptoms  from  the  pressure  the 
effused  fluid  caused. 

3171.  The  prognostic  in  hydrocephalus  must,  from  the  very 
nature  of  things,  be  unfavourable,  whether  it  be  idiopathic  or 
symptomatic,  under  any  hitherto  proposed  plan  of  treatment. 
This  appears  to  be  the  uniform  opinion  of  all  the  writers  we  have 
met  with  upon  this  subject.     Whytt  says,  he  never  cured  one 
that  had  the  characteristic  symptoms  of  this  disease;  while  others, 
asFothergill,  Percival,  &c.  declare  they  have  succeeded  in  curing 
the  disease.   Brichteau  says  he  has  succeeded  to  cure  one  in  six; 
while  Odier  states  his  success  to  have  been  one  in  five.     M. 
Itard  says  he  has  not  been  any  thing  like  so  fortunate,  though 
he  employed  every  known  remedy,  besides  obtaining  the  advice 
of  the  best  practitioners  in  Paris.  But  he  adds,  that  within  three 
years,  after  he  had  dared  to  introduce  the  vapour  baths  in  the 
treatment  of  this  complaint,  that  he  had  obtained  much  more 
flattering  results;  that  he  had  been  able  to  save  two  out  of  three 
children  he  treated  by  this  method.     We  will  not  pretend  to  fix 
the  proportion  of  our  success  to  our  failures ;  but  if  we  do  not 
deceive  ourselves,  we  may  say,  we  have  seen  hydrocephalus 


HYDROCEPHALUS    INTERNUS.  679 

cured  in  many  instances;*  and  some  we  have  at  least  seen  get 
well,  under  the  most  unpromising  appearances.  The  symptoma- 
tic form  of  this  disease  is  certainly  more  manageable  than  the 
idiopathic,  as  the  disease  from  which  it  proceeds  may  be  "  medi- 
cable," and  thus  giving  greater  chance  for  the  cure  of  the  other. 

3172.  The  signs  which  announce  a  favourable  change  taking 
Nlace,  are  1st,  an  abatement  of  vascular  and  cerebral  excitement, 
together  with  a  diminution  of  the  squinting ;  2d,  the  relaxation 
of  the  forehead  and  eyebrows;  3d,  the  stomach  retaining  its 
drinks,  and  the  bowels  discharging  a  newly-secreted  and  yellow 
bile ;  4th,  the  urine  depositing  a  lateritious  or  a  heavy  sediment; 
and  less  intensity  of  colour;  5th,  a  soft  skin,  from  gentle  trans- 
piration; 6th,  "  though  last  not  least,"  in  its  favourable  import, 
is  the  renewal  of  the  secretions  from  the  nostrils. 

3173.  Hydrocephalus,  it  is  said,  may  be  similated  by  a  variety 
of  other  diseases,  as  phrenitis,  ataxic  fever,  serous  apoplexy,  &c. 
Why  need  we  say  of  the  first  of  these,  that  it  similates  dropsy 
of  the  brain  ?     May  we  not  declare,  that  inflammation  or  irrita- 
tion is  the  absolute  cause  of  both  or  either?  And  that  the  others 
can  be  the  cause  of  symptomatic  hydrocephalus,  there  can  be  but 
little  doubt,  if  dissections  prove  any  thing. 

Dissection. 

3174.  Let  us  then  inquire  what  the  knife  reveals  to  us,  in 
those  who  have  died  of  the  acute  hydrocephalus.    1st.  "An  ex- 
treme engorgement  of  the  sinus  of  the  dura  mater,  and  of  the 
blood-vessels  spread  upon  the  brain  itself.     2d.  The  substance 

*  We  are  perfectly  persuaded,  that  this  truly  fatal  disease  may  many  times 
be  arrested  in  limine,  especially,  when  it  is  symptomatic  of  some  derangement 
of  the  abdominal  viscera.  For  there  is  a  period  in  almost  every  affection  of 
these  parts  of  an  acute  kind,  that  calls  into  morbid  action  some  portion  of  the 
cerebral  apparatus  whenever  there  is  a  disposition  in  the  brain  or  its  appen- 
dages to  take  on  morbid  action.  This  tendency  betrays  itself  many  days  before 
the  head  appears  to  be  involved  in  mischief — we  are  therefore  in  the  constant 
habit  of  watching  with  great  care  and  solicitude  the  progress  of  acute  (espe- 
cially) diseases  in  children.  Therefore,  we  become  extremely  solicitous,  when 
children  become  very  fretful,  (the  old  woman's  good  sign,')  while  labouring1 
under  any  acute  disease;  but  particularly  those  of  the  stomach  or  bowels,  if  the 
sleep  be  disturbed;  for  if  they  are  aroused  from  their  slumbers  shrieking,  and 
apparently,  frightened,  we  are  certain  that  mischief  is  brewing,  either  in  the 
head,  spinal  marrow,  or  both;  if  light  becomes  suddenly  offensive,  and  to  these 
symptoms  is  added  the  cough  as  noted  in  par.  3165.  When  this  train  of  signs 
present  themselves,  we  immediately  advertise  the  parents  or  friends  of  the  pa- 
tient of  the  threatened  mischief,  and  instantly  attack  it,  as  if  the  disease  so 
much  to  be  dreaded,  were  present.  By  anticipating  the  disease  in  this  manner, 
we  are  persuaded  we  have  saved  a  number  of  children  within  the  last  two 
years — though  we  must  at  the  same  time  confess,  even  this  timely  succour  does 
not  always  succeed. 


680  HYDROCEPHALUS    INJTEKNUS. 

of  the  brain  altered,  and  sometimes  softened  in  its  natural  con- 
sistence, but  most  commonly  firm,  and  very  elastic,  (r6nitent,) 
often  smeared  with  a  transparent  exudation,  or  an  absolute  layer 
of  pus.  3d.  Effusion  of  serum  to  a  greater  or  less  extent  in  the 
ventricles,  or  upon  the  surface  of  the,encephalon.  4th.  The  brain 
embued  with  a  serosity,  that  only  becomes  evident  by  cutting 
into  the  brain,  and  permitting  the  fluid  to  fill  up  the  gashes.  5th. 
Sometimes,  however,  no  part  of  the  brain  appears  to  be  moisten- 
ed by  any  unusual  portion  of  serum."  Itard. 

3175.  M.  Itard  asks,  "shall  we  from  this  condition  of  the 
brain,  conclude  that  a  hydrocephalus  did  not  exist,  though  the 
disease  was  strongly  marked  by  its  appropriate  symptoms?    I 
think  not,"  he  answers,   "for  the  effusion*  is  not  the  disease; 
it  is  only  the  consequence;  and  even  by  opening  the  body  we 
may  not  find  an  effusion,  either  because  it  may  have  been  ab- 
sorbed after  death,  or  what  is  more  likely,  that  the  irritation  of 
the  tunica  arachnoides  may  have  been  so  intense,  or  sufficiently 
deleterious,  to  cause  death  before  the  formation  of  the  effusion. 
Now,  we  know  that  similar  appearances  have  followed  from  the 
other  diseases  just  enumerated." 

3176.  In  the  abdomen,  lesions  are  also  to  be  found  ;  they  are 
the  result  of  a  sympathetic  influence,  between  the  brain  and  sto- 
mach, &c.     This  viscus  in  an  especial  manner  suffers  from  this 
cause;  hence  in  hydrocephalus,  it  is  found  engorged,  inflamed, 
or  suppurating ;  its  membrane  softened,  and  easily  destroyed  by 
the  finger.    We  may  also  observe  the  intestines  to  be  much  dis- 
ordered, by  inflammation,  invagination,  softened,  or  even  in  a 
state  of  incipient  gangrene ;  and  almost  always  containing  more 
or  less  worms.  The  liver  also  bears  marks  of  recent  engorgement. 

Acute  Symptomatic  Hydrocephalus. 

3177.  This  is  only  to  be  distinguished  from  the  species  just 
considered,  by  being  preceded  or  accompanied  by  some  other 

•  The  fluid,  or  lymph,  thrown  out  into  the  ventricles  of  the  brain,  was  de- 
clared by  Hunter  and  others,  not  to  coagulate  by  heat  or  other  agents,  like 
the  serous  effusions  of  the  abdomen  and  thoracic  cavities,  as  was  believed  by 
others.  M.  Haldat,  in  consequence  of  these  discrepant  opinions,  instituted  ex- 
periments to  determine  the  point,  and  gives  the  following  products  as  the  re- 
sult of  his  trials: — 

Water 96.0 

Muriate  of  soda    ---.----          1.5 

Albumen --          0.7 

Gelatine 1. 

Mucus  0.4 

Phosphate  of  soda  and  lime — a  trace;  loss     ...          0.4 
JImer.  Journ,  of  Med.  Scien.  for  Aug.  1832,  from  Journal  de  Physiologic,  Tom, 
LXXIII. 


HYDROCEPHALUS    INTERNUS.  681 

acute  idiopathic  affection.  This  species  is  doubtless  very  much 
more  common  than  the  idiopathic  species,  as  it  appears  to  be  the 
termination  of  many  other  diseases. 

3178.  That  fever,  be  its  type  what  it  may,  often  eventuates  in 
hydrocephalus,  we  can  have  no  doubt.     The  eruptive  fevers, 
however,  appear  to  be  more  special  causes  of  this  affection;  scar- 
latina, when  epidemic  in  Europe,  we  are  informed,  is  very  prone 
to  this  termination.    Cholera  infantum,  gastrites,  and  verminous 
fever,*  are  frequent  causes  of  this  sympathetic  disease.     Whytt 
says,  "a  scirrhous  tumour  of  the  glandula  pituitaria,  may  pro- 
duce hydrocephalus  internus."t 

Chronic  Idiopathic  Hydrocephalus. 

3179.  We  have  already  observed,  that  this  may  be  the  sequel 
to  an  acute  hydrocephalus;  or  it  may  proceed  from  an  hydropic 
diathesis  without  requiring  any  especial  condition  of  the  brain 
itself.     This  form  of  the  disease  has  been  subdivided,  1st,  into 
idiopathic  chronic  hydrocephalus,  properly  so  called.    This  dis- 
ease is  said  not  to  be  very  rare ;  and  indeed  if  we  take  for  grant- 
ed, that  every  enlargement  of  the  head  that  takes  place  after  two 
years,  and  perhaps  up  to  seven,  it  might  seem  to  be  proved.    If 
this  be  so,  certainly  this  complaint  is  not  necessarily  mortal ;  as 
we  see  children  with  heads  of  this  kind,  grow  up  to  manhood ; 
or  we  must  suppose  that  the  water  is  absorbed  and  the  cure 
effected  by  the  recuperative  powers  of  the  system  alone ;  or  that 
mere  pressure  from  effused  serum,  is  not  necessarily  productive 
of  death.    Sometimes,  however,  this  complaint  extends  itself,  so 
as  to  render  the  head  enormous,  and  at  the  same  time  truly 
hideous;  eighteen  pounds  of  water  it  is  said  have  been  found  in 
heads  of  this  kind.     This  complaint  gives  rise  to  various  dis- 

*  When  worms  infest  the  alimentary  canal,  a  chronic  fever  or  febricula  is 
sometimes  induced;  this  fever  is  almost  always  accompanied  by  drowsiness; 
flushed  cheek  or  cheeks;  hot  head;  paleness  of  face  except  when  flushed; 
emaciation;  cold  feet;  enlarged  abdomen;  grinding  of  the  teeth  during  sleep; 
starlings;  frequent  application  of  the  hands  to  the  head;  picking  or  rubbing 
the  nose;  and  squinting  more  or  less  confirmed.  In  this  account  we  see  a  very 
close  resemblance  to  the  more  prominent  symptoms  of  hydrooephalus,  and 
with  which  it  is  of  course  often  confounded.  We  remember  a  remarkable  case 
of  squinting  from  worms  in  a  little  girl  of  five  or  six  years  old.  The  parents 
were  much  alarmed  at  this  occurrence,  especially  as  it  had  made  its  appear- 
ance suddenly,  and  the  child  apparently  but  little  indisposed.  After  inquiring 
into  the  history  of  the  case,  we  were  satisfied  that  all  the  symptoms  justified 
the  belief  that  they  were  occasioned  by  the  presence  of  worms  in  the  intes- 
tines— we  ordered  her  the  pink  root,  (spigelia,)  in  appropriate  doses,  (see 
Chapter  on  Worms,*)  which  brought  away  many  lumbrici,  and  the  squinting, 
and  other  symptoms,  disappeared  immediately. 

f  Works,  p.  736, 

t  Diaeases  of  Children, 

86 


682  HYDROCEPHALUS  INTERNUS. 

turbances  of  the  system,  the  cause  of  which  is  easily  perceived, 
but  it  is  not  to  be  removed,  with  any  thing  like  certainty  in  any 
case  whatever.  The  other  disease  to  which  we  now  refer,  is, 
2d,  one  that  is  not  unfrequently  seen  among  children  of  an  early 
age;  commencing  generally  pretty  soon  after  birth,  and  con- 
tinuing to  an  indefinite  period. 

3180.  This  form  of  hydrocephalus  indeed,  was  for  a  long  time 
the  only  one  that  bore  the  name  of  chronic  dropsy  of  the  brain. 
Children  are  sometimes  born  alive  with  this  complaint,  though  we 
have  never  ourselves  witnessed  an  instance  of  it,  in  more  than 
ten  thousand  cases  of  births,  that  we  have  attended ;  on  two  oc- 
casions, we  were  obliged  to  open  hydropic  heads,*  &c.   before 
delivery  could  be  effected.     We  have  seen  this  complaint  show 
itself  a  few  weeks  after  birth,  and  have  known  it  to  proceed  to 
a  considerable  length ;  but  never  to  the  extent  recorded  by  se- 
veral writers. 

3181.  The  precise  situation  of  the  fluid  constituting  this  dis- 
ease has  not  been  agreed  upon  by  writers  upon  this  subject. 
Some  have  declared  that  the  water  was  placed  between  the  brain 
and  the  membranes,  while  others  say  it  is  found  in  the  cerebral 
cavities.  In  a  case  that  fell  under  the  notice  of  Dr.  Craigie  lately, 
it  was  clearly  ascertained,  that  the  fluid  was  contained  within 
the  parietes  of  the  cerebral  ventricles.     The  brain  in  this  case 
contained  a  gallon  of  fluid,  and  was  distended  to  five  or  six  times 
its  natural  capacity.     Dr.  C.  is  of  opinion,  that  this  affection  al- 
ways "  originates  as  an  acute  disease  in  the  central  surface  of  the 
brain. "  He  nevertheless  admits  the  possibility  of  the  fluid  getting 
"  out  of  this  situation,  and  insinuate  itself  between  the  outer  sur- 
face and  the  dura  mater;"  and  says  he  can  "  imagine  two  cases 
in  which  this  may  take  place.    The  first  is,  when  the  process  of 
serous  effusion  commences  at  a  period  so  early  in  the  foetal  exist- 
ence that  it  precedes  the  full  development  of  the  brain,  suddenly 
arrest  the  development,  while  the  pia  mater  and  the  choroid 
process  communicate  freely,  and  prevents  at  some  point  of  the 
mesial  plane,  cerebral  matter  from  being  deposited. "     The  se- 
cond, "  is  when  the  process  of  effusion  has  proceeded  to  such  an 
extreme  degree  as  to  lacerate  the  upper  and  most  attenuated  part 
of  the  hemispheres."     This,  however,  the  Doctor  admits  is  by 
no  means  easily  effected. — Edin.  Med.  and  Surg.  Journal  for 
July,  1832. 

3182.  This  disease,  we  believe,  rarely  admits  of  a  cure;  it  is 
almost  always  mortal,  for  death  takes  place  sooner  or  later  per- 
haps in  all  cases.  A  variety  of  means  have  been  proposed  for  its 

*  In  these  instances,  we  are  of  opinion,  the  children  had  died  some  time  be- 
fore birth,  as  their  bodies  bore  every  mark  of  disorganization. 


HYDROCEPHALUS  INTERNUS.  683 

cure ;  piercing  the  cranium  with  a  trocar ;  salivation  ;  and  ban- 
daging. The  first  plan  has  nothing  but  its  hardihood  to  recom- 
mend it;*  the  second,  it  is  said,  has  succeeded;  this  was  first  re- 
commended by  the  British  writers;  Brichteau,  by  this  means 
restored  the  general  health  of  a  child  of  four  years  old,  but  with- 
out diminishing  in  the  slightest  degree  the  size  of  the  head.  And 
the  late  Dr.  Jenner  spoke  favourably  of  bandaging  the  head.  We 
tried  this  plan  in  one  case  for  a  long  time,  but  without  the 
smallest  advantage.  The  history  of  these  two  affections,  will 
instantly  suggest  their  own  prognostics. 

Chronic  Symptomatic  Hydrocephalus. 

3183.  This  species  of  hydrocephalus  is  far  from  being  rare; 
for  independently  of  the  affections  which  are  proper  to  the  brain 
itself,  there  are  many  chronic  affections  of  other  portions  of  the 
body,  that  call  this  mass  into  action,  especially,  when  about  to 
terminate  unfavourably.  Thus  hooping-cough,  asthma,  chronic 
catarrh,  polypus  of  the  heart,  aneurisms  of  the  great  vessels,  may 
cause  a  serous  effusion  within  the  ventricles  of  the  brain,  or  upon 
its  surface.  Drying  up  old  sores  suddenly,  especially  in  aged 
people;  and  the  sudden  disappearance  of  a  scrofulous  tumour  has 

*  A  case  of  successful  tapping  of  the  brain  is  related  by  Mr.  Russel  in  the 
Edinburgh  Medical  and  Surgical  Journal,  for  July,  1832,  which  we  will  briefly 
relate.  A  little  girl  aged  eight  months  had  chronic  hydrocephalus.  This  head 
measured  twenty-three  inches  in  circumference,  and  fifteen  and  a  half  from 
the  meatus  of  one  ear  to  the  other.  Compression,  blistering,  mercury,  diure- 
tics, &c.  were  tried  in  vain;  the  head  continued  to  increase,  though  the  gene- 
ral health  of  the  child  appeared  good.  To  discharge  the  fluid  by  puncture, 
was  reserted  to — a  common  hydrocele  trocar  was  used.  This  was  "introduced 
about  half  an  inch  in  depth  on  the  right  side  of  the  anterior  fontanelle,  and 
three  ounces  of  serous  fluid  were  discharged  through  the  cannula.  A  piece  of 
adhesive  plaster  was  placed  over  the  puncture,  and  a  roller  applied  round  the 
head.  She  slept  well  that  night,  but  next  day  was  slightly  feverish,  and  con- 
tinued so  for  two  days  afterwards,  when  she  appeared  as  well  as  before  the 
operation."  Ten  days  after,  "the  puncture  was  repeated  in  the  same  manner 
on  the  opposite  side,  and  five  and  an  half  ounces  of  turbid  serum  were  eva- 
cuated, containing  several  flakes  of  lymph.  No  unfavourable  symptoms  follow- 
ed." Eleven  days  after,  the  size  of  the  head  was  diminished  two  andaquarter 
inches  across  the  vertex.  Twenty  days  after  the  trocar  was  again  inserted  near 
the  place  first  punctured,  as  far  as  the  meninges;  half  an  ounce  only  passed 
through  the  cannula.  "I  therefore  reintroduced  it,  and  entered  it  obliquely, 
about  an  inch  and  an  half  in  the  direction  of  the  ventricle,  and  upon  withdraw- 
ing it,  nine  ounces  of  serum  were  discharged  in  a  continued  stream."  The 
wound  was  closed.  The  pulse  became  feeble,  and  the  child  faint;  but  revived 
soon  after,  and  no  further  unpleasant  symptom  followed.  She  continued  im- 
proving for  three  weeks;  at  the  end  of  this  time,  the  former  symptoms  return- 
ed; an  obscure  fluctuation  could  be  perceived,  at  the  anterior  bregma.  She 
was  now  gently  salivated;  absorption  followed,  with  the  entire  removal  of  all 
her  hydrocephalic  symptoms. 


684  HYDROCEPHALUS    INTERNTTS. 

been  followed  by  a  similar  consequence.  In  addition  to  the  re- 
mote causes  of  chronic  hydrocephalus,  many  derangements  were 
it  important  to  our  subject,  of  the  brain  itself,  might  be  men- 
tioned. 

Of  the  Treatment. 

3184.  There  are  two  principal  indications  to  be  fulfilled,  in  the 
treatment  of  the  acute  forms  of  hydrocephalus — namely,  to  over- 
come the  irritation  or  inflammation  which  has  attacked  the  brain, 
so  as  to  prevent  effusion ;  and  to  endeavour  to  remove  the  serum, 
if  effusion  has  taken  place. 

3185.  The  first  is  to  be  answered  by  all  the  antiphlogistic 
means  in  our  power ;  as  bleeding,  general  and  local ;  purging  ; 
sweating;  topical  applications;  blistering,  and  mercury. 

1.  Bleeding. 

3186.  We  must  have  recourse  to  this  remedy,  so  soon  as  the 
disease  is  sufficiently  developed,  to  present  us  with  an  active 
and  quickened  pulse;  or  where,  from  the  confession  of  the  patient, 
when  able  to  make  the  acknowledgment,  that  there  is  head-ache; 
where  we  see  a  corrugated  forehead;  observe  an  aversion  to  light, 
fretfulness,  &c.     We  are  aware  that  many  practitioners  are  re- 
luctant to  bleed  in  the  beginning  of  this  disease,  because  they 
have  seen  all  these  symptoms  disappear  upon  the  child  being 
liberally  purged,  kept  quiet,  and  upon  a  strict  regimen,  with- 
out having  had  recourse  to  blood-letting.     This  we  admit  to 
have  happened — but  has  it  not  also  happened,  that   the   con- 
trary of  this  has  taken  place?  where  the  disease  ran  a  rapid  and 
fatal  course  ;  and  gave  the  attendant  cause  to  repent  his  having 
neglected  this  important  remedy  in  the  beginning — we  at  least 
acknowledge  this  to  have  happened  with  ourselves,  and  therefore 
suppose  it  may  have  taken  place  with  others. 

3187.  On  this  account  we  now  rarely  omit  to  have  blood  ab- 
stracted, either  by  the  lancet,  or  by  leeches.     From  the  arm, 
whenever  there  is  much  arterial  action,  with  manifest  cerebral 
irritation ;  by  leeches,  when  the  symptoms  are  less  palpable,  or 
more  moderate  ;  and  governed  by  the  same  rules,  we  repeat  it, 
pro  re  nata.     Much  importance  is  now  attached,  to  the  part  on 
which  leeches  are  to  be  placed ;  more  perhaps  sometimes,  than 
the  case  really  demands.     On  this  point,  our  selection  is  usually 
made,  by  the  opinion  we  form,  whether  the  symptoms  arise  from 
an  idiopathic  cause,  or  a  sympathetic  influence.     If  we  believe 
it  to  be  the  first,  we  order  them  to  the  temples  and  behind  the 


HYDROCEPHALTJS    INTERNUS.  685 

ears  ;*  if  the  second,  we  suppose  them  to  arise  from  some  irrita- 
tion in  the  chylopoietic  viscera,  and  direct  them  to  be  placed 
upon  the  epigastrium.  Itard  insists  upon  their  superior  useful- 
ness when  applied  to  the  lower  extremities. 

3188.  In  our  employment  of  blood-letting  in  hydrocephalus, 
we  are  always  governed  by  the  actual  state  of  the  system;  and 
never  prescribe  for  the  name  of  the  disease.  If  the  system  be 
prostrated  before  any  cerebral  affection  manifest  itself,  we  never 
bleed  from  the  arm  ;  and  we  use  leeches  only,  where  we  judge 
there  is  a  further  reduction  of  arterial  action  absolutely  necessary 
for  the  safety  of  the  system.  But  at  the  same  time,  we  are  in  the 
habit  of  using  other  remedies  in  conjunction  with  the  bleeding  ; 
especially  to  the  lower  extremities — these  remedies  may  be, 
warm  water  and  mustard,  sinapisms,  or  blisters.  As  regards  the 
quantity  of  blood  to  be  drawn,  we  can  lay  down  but  one  fixed 
rule — namely,  to  regulate  the  quantity,  by  the  exigency  of  the 
case,  and  the  age  and  strength  of  the  patient.  We  are  aware 
that  this  practical  direction,  is  one  very  difficult  to  regulate  with 
any  certainty;  nor  can  we  lay  down  any  positive  directions  to 
aid  the  discrimination  of  the  young  practitioner — for  it  is  a  tact, 
only  to  be  acquired  by  long  experience  and  close  observation. 
We  may  nevertheless  describe  situations  of  the  system,  in  which 
blood-letting  is  not  indicated,  if  it  be  not  positively  forbidden, 
but  on  which  much  reliance  has  been  placed,  especially  in  the 
disease  under  consideration.  First,  a  rapid  or  very  frequent 
pulse,  especially  when  attended  by  a  warm  skin  where  the  body 
is  clothed.  Now  in  this  case,  one  of  the  last  efforts  of  the  sys- 
tem to  preserve  life  by  increasing  the  circulation,  and  the  extri- 
cation of  caloric,  is  mistaken  for  an  indication  to  abstract  blood; 
for  these  phenomena  take  place  in  animals,  nearly  bled  to  death. 
Second,  violent  throbbing  of  the  carotids.  This  phenomenon  has 
misled  in  very  many  instances  the  young  practitioner,  especially, 

*  The  propriety  of  applying  leeches  behind  the  ears,  or  indeed  to  any  pact 
of  the  head  is  very  stoutly  disputed  by  Dr.  Ballieu;  and  if  we  can  take  his 
cases  as  evidence,  their  application  to  these  parts  not  only  fails  to  relieve,  but 
really  increases  every  symptom.  This  does  not  however  accord  with  our  own 
experience,  so  far  as  this  can  be  trusted — or  at  least,  hitherto  we  have  had  no 
reason  to  suspect  an  unfriendly  effect  upon  the  patient;  though  we  have 
had  reason  but  too  often,  to  lament  their  want  of  success — we  shall  however 
in  future  be  more  attentive  to  their  influence.  Dr.  B.  supposes  the  injury 
arises  from  the  transmission  of  irritation  through  the  course  of  the  nerves  to 
the  brain,  from  the  little  bites,  Cmordillement"}  of  the  leeches.  He  says,  "  J'ai 
toujours  pense  que  1'irritation  produite  a  1'une  des  extre"mit6s  des  nerfs  par  le 
long  mordillement  qu'  exercent  les  sangsues,  doit  so  propager  a  1'autre  extr£- 
mite';  c'est  ansi  que  1'excitation  des  canaux  secre'teurs  se  transmet  par  conti- 
nuity de  tissue  jusqu'  aux  glands  ou  ils  vont  aboutir."  p.  9.  From  this  it  will 
be  seen  that  he  coincides  with  Itard,  and  from  whom  he  perhaps  has  borrowed 
the  sentiment,  without  acknowledgment. 


686  HYDROCEPHALUS    INTERNUS. 

after  pretty  liberal  depletion  has  been  practised.  But  this  ap- 
pearance, like  the  former,  is  among  the  last  conservative  efforts 
of  the  system,  for  the  continuance  of  life — blood  is  sped  with  un- 
usual celerity,  and  in  unnatural  quantities  to  the  brain,  that  re- 
spiration may  be  maintained  as  long  as  possible  ;  and  to  such  a 
degree  is  this  last  effort  carried  sometimes,  that  in  some  cases  of 
hydrocephalus  internus  attended  with  extreme  congestion  of  the 
thoracic  or  abdominal  viscera,  as  well  as  in  exhausting  hsemor- 
rhagies,  that  the  vessels  of  the  meninges  of  the  brain  have  been 
found  turgid  with  blood,  and  even  watery  effusion  in  the  ven- 
tricles. But  do  not  let  us  be  understood  as  declaring,  that  these 
phenomena  are  the  result  of  debility,  and  require  stimuli  for 
their  cure — this  we  do  not  believe ;  for  were  debility  the  cause 
of  the  accumulation  of  the  blood,  or  of  the  effusion  of  serum, 
every  brain  should  exhibit  the  same  appearances  after  death  ;  as 
death  is  the  greatest  possible  debility.  And  though  we  admit, 
that  further  depletion  would  be  injurious,  we  are  every  way  cer- 
tain that  stimuli  would  be  equally  unprofitable — at  least  we  have 
never  seen  them  useful,  when  the  system  had  arrived  as  we  sup- 
posed, to  the  condition  that  required  the  increase  of  cerebral  cir- 
culation, for  the  continuance  of  life. 

2.  Purging. 

3189.  This  remedy  cannot  be  dispensed  with,  in  either  form 
of  hydrocephalus — in  the  acute,  it  is  essential,  as  no  other  re- 
medy with  which  we  are  acquainted  relieves  the  head  of  its 
superfluous  blood   like   purging — this  effect  is  not  difficult  to 
understand  if  we  call  to  mind  the  direct  communication  of  the 
blood-vessels  of  the  abdomen  and  the  head.    Some  indeed  are  of 
opinion  that  purging  is  more  to  be  relied  upon  than  the  abstrac- 
tion of  blood — we  are  also  of  this  opinion  quo  ad  hoc  ;  namely, 
where  a  morbid  condition  of  any  of  the  abdominal  viscera  give 
rise  to  the  cerebral  irritation ;  but  where  the  affection  of  the 
brain  is  really  idiopathic,  we  believe  this  is  not  the  case.     The 
case  related  by  Cheyne  where,  "  two  chamber-potfuls  of  the 
most  extraordinary  faeces,"  were  brought  away  is  a*  case  in  point. 
But  notwithstanding  our  conviction  of  the  efficacy  of  purging  in 
hydrocephalus,  it  must  nevertheless  be  understood,  that  it  is 
only  certainly,  and  extensively  useful,  in  the  idiopathic,  acute 
hydrocephalus,  and  after  the  system  has  been  lowered  by  a  pre- 
vious bleeding,  or  bleedings.     Not  so,  perhaps  in  the  sympto- 
matic species — in  this  variety,  purging  may  be  of  paramount  be- 
nefit to  bleeding,  as  the  case  just  cited  appears  to  prove. 

3190.  But  in  either  case  we  purge — whether  bleeding  has  been 
premised  or  not.     For  this  purpose  we  prefer  a  few  grains  of 


HYDROCEPHALUS    INTERNUS.  687 

calomel,  followed  in  two  or  three  hours  by  castor  oil  or  mag- 
nesia, should  the  calomel  not  have  operated  sufficiently.  We 
persist  in  this  plan  daily;  unless  we  see  some  evidence,  that 
this  remedy  has  been  carried  far  enough,  by  only  very  small, 
green,  and  frequent  stools  succeeding  to  their  exhibition;  or  if 
the  evacuations  become  watery,  or  accompanied  by  some  of  the 
mucus  from  the  bowels.  After  a  free  purging  has  been  instituted, 
and  we  think  it  no  longer  desirable  to  persevere  in  it,  we  maintain 
a  sufficient  action  of  the  bowels  by  very  minute  doses  of  calomel, 
that  is,  from  a  quarter  to  half  a  grain  every  two  or  three  hours, 
or  by  small  doses  of  castor  oil.  It  may  be  proper  however,  to 
suggest  a  caution  to  the  young  practitioner  here,  not  to  persist 
too  long  in  cathartic  medicines,  by  reminding  him,  that  in  most 
instances,  the  stools  will  appear  of  a  dark-green  colour,  purge  as 
we  may ;  therefore  that  further  purging  is  not  called  for  from 
the  mere  appearance  of  the  evacuations. 

3.  Sweating. 

3191.  By  sweating,  in  this  place,  we  would  only  wish  to  be 
understood,  the  exhibition  of  such  medicine  as  have  a  tendency 
to  produce  diaphoresis,  without  expecting  a  profuse  discharge  like 
that,  which  take  place  upon  the  solution  of  fever  of  regular  type. 
For  though  fever  is  an  almost  constant  attendant  on  the  disease 
in  question,  yet  it  has  no  uniform   termination ;   but  notwith- 
standing this,  we  think  we  have  seen  advantage  follow  the  exhi- 
bition of  the  tartrite  of  antimony  in  minute  doses;  that  is,  from 
the  tenth  to  the  twentieth  part  of  a  grain,  exhibited  every  two 
or  three  hours — or  the  eighth  or  tenth  of  a  grain  of  ipecacuanha 
at  the  same  intervals. 

4.    Topical  Applications,  and  Blistering. 

3192.  The  topical  applications  besides  blisters,  are  cold  to  the 
head  ;*  pediluvium ;  and  sinapisms.     For  the  first  to  be  suc- 
cessful, the  hair  should  be  cut  off,  or  the  head  shaved — the  best 
mode  of  applying  the  water,  is  by  a  bladder  of  large  size  par- 
tially filled  with  cold  water,  or  ice  and  water.  These  applications 
should  not  be  continued  too  long  at  a  time ;  therefore,  when  the 
temperature  of  the  head  is  well  reduced,  they  should  be  remov- 
ed, and  not  again  applied  until  the  head  becomes  warm. 

*  Ballieu  is  very  suspicious  of  this  remedy;  and  doubts  its  agency  in  the  re- 
covery of  patients  where  it  had  been  considered  as  an  efficient  means;  while 
he  commends  blisters  in  the  highest  terms,  if  applied  to  the  lower  extremities, 
and  in  the  early  stage  of  the  disease. — Memoirs,  sur  le  traitement  de  I' inflamma- 
tion du  cerveau,  &c.  p,  46. 


688  HYDROCEPHALUS    INTERNUS. 

3193.  Sinapisms  are  only  proper  where  there  is  a  reduced  pulse, 
and  a  tendency  in  the  extremities  to  become  cold — they  may 
then  be  applied  to  these  parts  with  advantage,  until  the  skin  be- 
comes red,  but  no  longer.     They  may  be  renewed  however,  as 
occasion  may  require ;  or  when  the  redness  goes  off.     In  these 
directions  however  we  differ  from  Ballieu,  who  thinks  them  very 
advantageous  in  the  early  stage  of  the  disease,  especially  when 
suffered  to  remain  sufficiently  long  to  cause  blistering.   He  says, 
"  how  often  do  we  see  violent  head-ache,  even  delirium,  remov- 
ed by  large  sinapisms  applied  to  the  feet?  and  perhaps  sinapisms 
pushed  to  blistering,  are,  among  the  best  derivatives ;  and  those 
in  which  the  pain  persists,  that  is  caused   by  them."     With  a 
view  to  enforce  this  practical  view,  he  declares,  that  a  certain 
child  was  twice  seized  with  inflammation  of  the  brain ;  in  both 
instances,  the  disease   was  cured  by  sinapisms  applied  to  the 
insteps ;  in  neither  instance  were  "the  sinapisms  preceded  by 
bleeding.* 

3194.  Pediluvium  may  be  had  recourse  to  from  time  to  time, 
especially  if  the  determination  to  the  head  be  strong,  and  the 
legs  and  feet  rather  cold ;  in  the  latter  case,  a  little  flour  of  mus- 
tard should  be  mingled  with  the  water. 

3195.  Blisters  are  to  be  applied  to  the  legs  and  thighs  alter- 
nately if  necessary,  as  soon  as  the  first  stage  threatens  a  conver- 
sion into  the  second ;  and  they  may  be  repeated  at  the  end  of  the 
disease.   Many  prefer  the  head  ;  but  this  is  certainly  an  inconve- 
nient part  to  blister,  if  it  be  not  an  improper  one ;  and  if  we  can 
place  reliance  upon  our  own  experience,  we  have  thought  it  in- 
jurious in  many  instances.     To  the  nape  of  the  neck,  is  much 
better  as  regards  effects ;  but  the  position  is  certainly  a  most  fa- 
tiguing one  to  the  patient — we  have  therefore  for  the  last  thirty 
years;  rarely  applied  them  to  this  part;  believing  most  firmly 
that  more  advantage  is  derived  from  their  employment  upon  the 
extremities. 

3196.  After  effusion  has  certainly  taken  pfece,  we  have  little 
to  hope  for,  or  to  rely  upon — absorption  we  have  reason  to  be- 
lieve, can  rarely  take  place,  from  even  the  anatomical  arrangement 
of  the  brain  itself;  and  our  means  to  aid  this,  with  our  present 
limited  knowledge,  is  almost  confined  to  one  article;  namely, 
mercury,  freely  urged  by  the  mouth,  and  by  the  skin.     This 
remedy  in  such  cases,  certainly  deserves  a  trial,  for  as  far  as  the 
facts  can  be  proved   by  our  senses,  and   belief,  a  number  have 
recovered  under  its  use,  since  it  was  first  recommended  in  1775,. 
by  Dr.  Dobson,  of  Liverpool. 

•  Memoire  sur  le  traitcment  de  1'inflammation  du  cerveau,  8cc.  p.  15. 


HYDRO-THORAX.  689 


SECT.  II. — HYDRO-THORAX. 

3197.  We  have  already  remarked  how  much  obscurity  has 
hitherto  prevailed,  respecting  both  the  acute  and  chronic  affec- 
tions of  the  thorax;  and  at  the  same  time  took  occasion  to  ob- 
serve, that  the  profession  is  largely  indebted  to  Laennec,  Bayle, 
Andral,  &c.  for  the  light  which  is  now  spread  upon  this  important 
class  of  diseases.  We  take  the  present  occasion  to  enforce,  what  we 
then  suggested,  namely,  the  importance  of  the  study  of  ausculta- 
tion, if  we  wish  to  arrive  at  correct  diagnoses  of  the  various  affec- 
tions to  which  the  thorax  and  its  contents,  are  liable.   At  the  same 
time  let  us  also  recommend  the  study  of  morbid  anatomy,  by 
taking  advantage  of  every  opportunity  that  may  present  itself, 
to  make  post  mortem  examinations.    To  these  two  causes,  auscul- 
tation, and  autopsic  examinations,  are  we  indebted  for  the  ana- 
tomical character  of  hydrothorax;  for  a  history  of  its  symptoms,* 
and  for  the  discovery  of  its  infrequency  as  an  idiopathic  disease; 
for  such  appears  to  be  the  fact,  while  we  have  been  led  to  be- 
lieve, from  the  study  of  the  mere  constitutional  symptoms,  that 
it  is  one  of  very  frequent  occurrence.     Nor  is  this  to  surprise 
us,  since  auscultation  is  a  very  late  discovery,  and  post  mortem 
examinations  are  comparatively  very  rare.     It  must  not  then 
excite  too  much  wonder  in  those  who  are  altogether  unacquainted 
with  the  one,  and  very  little  familiar  with  the  other,  when  he 
finds  according  to  Laennec,   the  extreme  rarity  of  idiopathic 
hydrothorax. 

3198.  We  have  resorted  to  this  author,  for  information,  upon 
this  subject,  because  his  account  of  this  disease  is  the  absolute 
result  of  autopsic  investigations ;  the  only  ones  that  should  be 
considered  authentic  or  satisfactory.    It  would  be  idle  at  the  pre- 
sent moment  to  seek  for  pathological  information  from  the  older 
writers,  upon  the  subject  of  hydrothorax;  for  we  could  not  but  be 
misled,  by  such  an  appeal.     It  is  true,  they  describe  with  great 
minuteness   and   circumstantiality,  a  disease   purporting  to  be 
hydrothorax ;  its  diagnostics  are  attempted  to  be  ascertained  and 
to  be  faithfully  laid  down  ;  and  the  mode  of  treatment  is,  formally 
detailed — the  patient  dies,  and  the  knife  reveals,  that  there  is  an 
affection  of  the  heart,  or  its  great  blood-vessels,  or  some  visceral 
derangement,  instead  of  an  accumulation  of  water  in  the  chest. 
This  is  no  uncommon  occurrence;  and  this  kind  of  error  must 
necessarily  be  perpetuated,  if  practitioners  will  persist  to  copy 
from  each  other,  the  details  of  symptoms  purporting  to  be  hydro- 
thorax,  but  which  dissection  proves  to  be  altogether  suppositi- 
tious, instead  of  learning  its  history  and  symptoms  from  an  au- 
thentic source.     It  is  therefore  time  that  this  error  should  be 

87 


690  HYDROTHORAX. 

exposed,  by  an  appeal  to  an  authority,  whose  testimony  cannot 
be  doubted,  and  who  has  only  detailed  the  facts,  his  knife  has 
discovered. 

3199.  This  author  says,  "this  disease"    (Idiopathic  hydro- 
thorax,)  "  is  considered  by  many  practitioners,  and  by  extra- 
professional  persons  generally,  as  a  very  common  disease,  and  a 
frequent  cause  of  death.     When  truly  idiopathic  however,  and 
existing  in  a  degree  to  occasion  death  by  itself,  I  consider  it  one 
of  the  rarest  diseases;  and  do  not  think  we  are  justified  in  rating 
its  fatality  higher  than  one  in  two  thousand  deaths.    I  have  often 
seen  practitioners,  who  were  but  imperfectly  acquainted  with 
morbid  anatomy,  and  consequently  very  ignorant  of  diagnosis, 
mistake  for  this  affection,  hypertrophy  of  the  heart,  aneurism  of 
the  aorta,  irregular  consumption,  and  even  scirrhous  of  the  sto- 
mach— when  there  was  no  coexisting  effusion  into  the  pleura,  or 
at  least,  none  other  except  what  took  place  immediately  preced- 

1  ing  death."  p.  4S4.  In  this  brief  statement  we  discover  the 
many  sources,  from  which  errors  may  flow,  on  the  subject  of 
hydrothorax.  Another  however,  he  says,  arises  from  mistaking 
the  sero-purulent  effusion  of  pleurisy,  for  the  fluid  of  dropsy — 
this  fact  merits  particular  attention ;  as  it  serves  to  explain  the 
cause  of  the  supposed  frequency  of  this  disease. 

3200.  He  further  informs  us,  that  "idiopathic  hydrothorax 
commonly  exists  only  on  one  side.  Its  anatomical  characters  are 
simply  an  accumulation  of  serum  in  the  cavity  of  the  pleura;  this 
membrane  being  quite  healthy  in  other  respects;  and  the  lung 
being  compressed  towards  the  mediastinum,  flaccid,  and  destitute 
of  air,  as  in  cases  of  pleuritic  effusion.    When  the  effusion  is  very 
great,  the  affected  side  is  evidently  larger  than  the  other.  In  one 
case  of  this  kind,  the  right  pleura  contained  twelve  pounds  of  a 
colourless  and  limpid  serum,  and  seemed  in  other  respects  quite 
healthy."  This  disease  is  so  rare,  that  Laennec  does  not  think  it 
necessary  to  say  any  thing  on  the  mode  of  cure. 

"Signs  and  Symptoms." 

3201.  "The  chief  and  almost  the  only  symptom  of  this 
disease  is  the  impeded  respiration."  How  different  is  this  sim- 
ple and  indisputable  statement  from  the  elaborate,  nay,  in  some 
instances,  eloquent  description  of  a  disease,  purporting  to  be 
hydrothorax  ?    Where  is  "  the  sense  of  weight  or  oppression  re- 
ferred to  the  pit  of  the  stomach,  starting  in  the  sleep,"  &c.  &c. 
&c.  so  frequently  recorded  ?    It  must  be  acknowledged  that  they 
are  not  declaratory  of  idiopathic  hydrothorax,  though  they  may 
accompany  the  symptomatic  form  of  this  disease. 

3202.  "  Percussion  affords  the  dead  sound;  and  the  stethoscope 


HYDROTHORAX.  691 

the  absence  of  respiration  every  where  except  at  the  roots  of  the 
lungs."     jEgophonism  also  attends. 

3203.  On  the  cause  of  this  disease  he  makes  the  following  in- 
teresting remarks,  which  are  corroborative,  if  not  confirmative, 
of  the  views  we  have  taken  of  dropsy  in  general,  and  tending 
much  to  establish  the  suggestions  lately  made  by  several  respec- 
table writers,  as  Blackall,  Parry,  &c.  upon  this  disease.    "What- 
ever may  be  the  difference,  both  in  the  general  symptoms  and 
the  organic  lesions,  between  a  case  of  hydrothorax  and  an  acute 
pleurisy,  or  between  a  case  of  ascites  from  general  debility  or 
organic  disease  of  the  heart  or  liver,  and  the  same  disease  from 
an  attack  of  peritonitis;  or,  in  short,  whatever  may  be  the  dif- 
ference in  general,  betioeen.  a  dropsy  and  an  inflammation — 
there  can  be  no  doubt  that  these  two  affections,  so  opposite  in 
their  extreme  degrees,  are  nevertheless  often  very  nearly  allied 
in  their  slighter  shades.     We  frequently  find  amid  the  serum  of 
ascites  or  hydrothorax,  filaments  of  a  milk-white  or  yellowish 
colour,  and  semitransparent,  formed  of  concrete  albumen,  almost 
as  solid  as  false  membrane.     Thus,  for  instance,  it  is  not  always 
easy  to  distinguish  between  oedema  of  the  lungs  from  the  first 
degree  of  peripneumony."  p.  486. 

3204.  From  this  statement,  we  think  it  may  be  inferred  with 
safety,  if  not  with  certainty,  that  the  idiopathic,  as  well  as  the 
symptomatic  hydrothorax,  is  like   most  other  dropsies,   only 
the  effects  of  previous,  or  existing  inflammation.     For  it  is  the 
habit  of  the  serous  membranes,  wherever  situated,  to  throw  out 
a  fluid,  whenever  irritated  or  inflamed;  and  consequently,  that 
our  therapeutical  views  must  be  based  upon  the  presumption,  in 
most  instances,  of  a  still  existing  inflammation,  either  active  or 
sub-acute,  as  in  ascites,  hydrocephalus,  hydrocele,  &c.     It  would 
also  lead  us  to  the  conclusion,  that  the  exact  degree  of  inflamma- 
tion necessary  to  the  formation  of  idiopathic  hydrothorax  must 
be  extremely  rare;  whereas  that  degree  which  may  eventuate  in 
the  symptomatic  must  be  very  much  more  common.    Or  in  other 
words,  from  the  susceptibility  of  the  pleura  to  active  inflamma- 
tion, it  quickly  acquires  a  degree  of  it  transcending  that  which 
would  relieve  itself  completely,  or  nearly  so,  by  the  effusion  of 
serum,  and  thus  form  the  idiopathic  hydrothorax. 

Symptomatic  Hydrothorax. 

3205.  Laennec  informs  us,  that  this  species  is  as  common,  as  the 
other  is  rare.    That  it  may  accompany  almost  any  disease;  whe- 
ther that  disease  be  acute  or  chronic,  and  its  presence  announces 
the  approach  of  death,  which  it  often  precedes  only  a  few  mo- 
ments.     This  is  a  curious  pathological  statement ;  but  from  the 


692  HYDROTHORAX. 

respectability  of  the  authority  for  it,  we  are  almost  bound  to  re- 
ceive it  as  a  fact.  And  what  adds  to  the  peculiarity  of  this  species 
of  dropsy  is,  that  it  does  not  take  place  more  frequently  perhaps, 
agreeably  to  the  same  authority,  in  cases  of  ascites  and  general 
anasarca,  than  in  other  diseases — its  existence  then  does  not  ap- 
pear to  depend  upon  an  hydropic  diathesis  of  the  constitution, 
since  it  seems  to  occur  as  frequently  where  this  does  not  exist, 
as  when  it  is  present.  Hence  it  is  found  in  those  "  who  die  of 
acute  fever,  diseases  of  the  heart,  or  tubercles  or  cancer  of  differ- 
ent organs." 

3206.  Its  symptoms  resemble,  in  every  respect,  those  produc- 
ed by  the  idiopathic  form  of  this  disease,  but  the)7  do  not  discover 
themselves  but  a  few  days,  or  even  hours  before  death.     How 
different  is  this  statement  of  Laennec  from  the  impressions  ge- 
nerally received  of  the  obstinate  character  and  permanent  nature 
of  this  disease — is  it  not  a  common  belief  that  this  complaint 
may  continue  for  a  very  long  time,  nay  for  years?     Whence 
arises  this  error?  We  have  partly  explained  this  above;  namely, 
by  the  infrequency  of  post  mortem  examinations,  and  therefore 
almost  exclusively  relying  upon  constitutional  symptoms,  for  the 
existence  of  the  disease. 

3207.  Our  author  declares  in  round  terms,  that  "  nothing  is 
more  uncommon,  even  in  organic  affections  of  the  liver  and 
heart,  attended  by  ascites  and  general  anasarca,  than  to  meet 
with  the  signs  of  hydrothorax  so  long  as  eight  days  before  death. 
We  may  consider  this  disease  as  peculiar  to  the  moribund." 
Notwithstanding  this  account  runs  counter  to  all  our  notions  of 
this  disease,  we  are  bound  almost  implicitl}7  to  rely  upon  it,  as 
it  is  furnished  by  the  most  unexceptionable  authority  ;  and  this 
circumstance  alone  will  show  the  value  of  pathological  researches, 
and  incite  we  trust  the  student,  and  young  practitioner,  to  the 
study  of  morbid  anatomy  in  all  its  various  relations,  with  the 
energy  and  devotion  they  so  justly  claim. 

3208.  Laennec,  as  we  have  already  observed,  does  not  pro- 
pose any  treatment  for  idiopathic  hydrothorax,  as  it  is  so  ex- 
tremely rare — but  he  deprecates  the  conclusion,  that  it  is  incura- 
ble, because  it  is  complicated  with  disease  of  the  heart.   In  proof 
of  this,  he  relates  the  case  of  a  woman,  who  had,  besides  effusion 
in  the  left  side  of  the  thorax,  hypertrophy  and  dilatation  of  the 
heart,  who  was  cured  of  the  hydrothorax  by  the  acetate  of  pot- 
ash, to  the  amount  of  an  ounce  to  an  ounce  and  an  half  daily,  as 
also  nitre  in  closes  increased  from  one  to  two  scruples.     This 
patient  returned  to  the  hospital  a  year  after,  affected  with  acute 
pleuro-pneumonia  of  the  right  side,  of  which  she  died — on  exa- 
mining her  after  death,  the  left  lung  was  found  perfectly  free 
from  adhesions. 


ASCITES.  693 

3209.  It  would  not  perhaps  be  either  fair  or  safe,  to  draw  any 
positive  conclusion  from  this  case,  as  regards  the  cause  of  hydro- 
thorax — yet  it  would  seem  to  justify  the  inference,  that  affections 
of  the  heart  are  not  necessarily  the  cause  of  this  disease,  when 
they  exist  in   combination  ;  or  that  it  is  instrumental  even  in 
maintaining  it,  when  it  may  have  proceeded  from  another  cause; 
for  this  woman  was  relieved  of  the  effused  serum  by  the  remedies 
employed,  and  which  did  not  return,  though  the  disease  of  the 
heart  persisted.    In  this  case  diuretics  and  purgatives  were  alone 
resorted  to  ;  and  the  general  treatment  is  precisely  like  that  of 
chronic  pleurisy,  of  which  we  have  already  treated,  and  which 
see,  p.  492. 

3210.  It  may,  however,  be  proper  to  mention  the  high  cha- 
racter that  digitalis  has  obtained  in  effusions  of  the  chest — by 
some  it  is  looked  upon  almost  as  a  specific ;  and  all  seem  to  agree 
that  it  is  almost  uniformly  successful  in  carrying  off  water  or 
the  effused  fluid  from  this  part  more  certainly  than  any  other 
remedy,  at  least  for  a  time.      For  this  purpose  it  is  said  that 
large  doses  are  required,  and  its  best  form  is  that  of  infusion. 
We  have,  however,  always  had  some  dread   of  this  medicine  ; 
and  we  would  recommend  a  close  attention  to  the  pulse,  head 
and  stomach,  during  its  administration — if  the  pulse  become  pre- 
ternaturally  slow,  if  the  head  is  found  to  be  confused  or  giddy, 
or  the  stomach  very  sick,  we  would  diminish  the  dose,  or  sus- 
pend its  use  altogether. 

SECT.  III. — ASCITES,  OR  ABDOMINAL  DROPSY. 

3211.  When  water  occupies  the  abdominal  cavity,  it  is  called 
ascites,  and  is  generally  found  to  result,  from  visceral  derange- 
ment, protracted  miasmatic  diseases,  sudden  cold,  obstructed  ca- 
tamenia,  too  frequent  indulgence  in  alcoholic  liquors,  chronic 
diarrhoeas,  &c.  but  more  especially,  it  is  supposed  by  many,  to 
arise  from  previous  peritoneal  inflammation. 

3212.  The  disease  may  take  place  suddenly,  or  more  slowly, 
according  to  the  nature  of  the  remote  cause  and  predisposition  of 
the  body — it  is  most  apt  to  occur  suddenly  in  young  subjects; 
and  especially,  in  young  females  before  puberty,  when  they  have 
been  affected  by  a  previous  acute  disease,  as  an  intermittent,  or 
a  ramittent  fever;  more  slowly  in  more  aged  persons.     In  two 
instances,  we  knew  this  form  of  dropsy  come  on  pretty  rapidly, 
as  the  marks  of  puberty  were  declaring  themselves;  but  in  which 
the  catamenial  discharge  did  not  take  place,  until  this  complaint 
was  removed.  Was  this  occasioned  by  any  particular  excitement 
of  the  ovaries  at  this  time?  Or  was  there  a  transfer  of  the  cata- 


694  ASCITES. 

menial  excitement  to  the  peritoneum,  urging  it  to  the  effusion  of 
serum,  or  the  secretion  of  lymph  ?  In  the  cases  just  alluded  to, 
there  was  no  previous  ill  health  to  account  for  this  affection;  for 
in  both  instances,  the  young  ladies'  health  did  not  appear  to 
change,  until  after  the  abdomen  was  observed  to  swell. 

3213.  When  this  disease  is  the  consequence  of  previous  ill- 
health,  and  especially  when  this  is  from  diseased  viscera,  the 
complexion  is  sallow,  the  flesh  soft  and  oftentimes  doughy,  the 
skin  dry,  the  bowels  costive,  or  too  open,  urine  scanty  and  load- 
ed, appetite  bad,  digestion  impaired,  listlessness,  &c.     These 
symptoms  are  sooner  or  later  followed  by  a- sensation  of  stiffness, 
first  observed  by  the  patient  when  about  to  stoop,  and  soon  after 
the  abdomen  is  perceived  to  swell,  the  respiration  hurried  upon 
any  quick  motion,  and  particularly  upon  going  up  stairs. 

3214.  The  feet  and  ankles,  especially  towards  night,  may  be 
observed  to  swell,  and  again  disappear  during  the  night.     This, 
however,  is  not  a  constant  symptom,  for  we  have  known  it  to  be 
absent  in  a  number  of  instances  of  confirmed  ascites,  even  where 
paracentesis  has  been  performed.     There  was  no  swelling  of  the 
limbs  in  either  of  the  cases  of  the  young  ladies  above  mentioned; 
nor  is  it  an  attendant  upon  a  case  we  have  now  under  care.  This 
is  a  female  near  fifty  years  of  age,  and  with  whom  the  menses 
have  been  several  years  absent ;  the  cause  of  the  dropsy  is  very 
uncertain. 

3215.  The  swelling  is  ordinarily  first  perceived  in  the  epigas- 
tric region,  but  it  gradually  extends  over  the  whole  abdomen.   If 
the  case  be  complicated  with  anasarca,  this  is  also  found  to  aug- 
ment, and  as  the  disease  progresses,  much  additional  inconve- 
nience is  experienced;  the  skin  is  very  dry  and  husky;  costive- 
ness  ;  mouth  clammy  ;  thirst  intense  sometimes ;  cough  occasion- 
ally, and  without  expectoration;  breathing  frequent,  sometimes 
laborious,  particularly  when  in  a  recumbent  position.     As  the 
distention  of  the  abdomen  increases,  the  symptoms  depending 
upon  it  augment;  eventually  the  cellular  tissue  of  the  whole  body 
becomes  filled,  in  which  the  thorax  participates,  and  thus  pro- 
duces universal  dropsy. 

3216.  In  the  beginning  the  pulse  is  active,  and  corded  most 
generally,  but  at  other  times  it  is  feeble  and  frequent.  Eventually 
hectic  irritation  ensues.   The  patient  now  declines  rapidly,  ema- 
ciation becomes  extreme,  diarrhoea,  difficulty  of  breathing,  *ed 
tongue,  aphthae,  and  almost  an  entire  suppression  of  urine ;  what 
little  there  is,  is  high-coloured,  and  perhaps  offensive;  extreme 
exhaustion,  and  death. 


ASCITES.  695 


Diagnosis. 

3217.  Notwithstanding  the  strongly-marked  character  of  as- 
cites,  pregnancy  has  been  mistaken  for  it,  and  the  reverse.     In 
these  cases,  we  are  disposed  to  believe,  that  much  carelessness 
must  have  prevailed,  as  they  have  no  symptom  in  common  that 
should  be  mistaken,  if  we  except  swelling.   But  the  evident  and 
decided  fluctuation  of  ascites  can  never  be  mistaken,  by  one  who 
has  ever  struck  the  abdomen  with  the  view  of  producing  it. 
Pregnancy  can  only  be  confounded  with  ovarian  or  encysted 
dropsy,  and  this  not  readily  by  one  ordinarily  skilled  in  obste- 
trics, which,  if  he  be  not,  it  becomes  a  duty  to  consult  one  who 
is,  before  he  proceeds  to  measures  that  might  endanger  the  foetus 
in  utero.  Even  in  complications  of  pregnancy  with  ascites,  little 
embarrassment  need  occur;  since  a  well-directed  inquiry,  and  an 
honest  history  of  symptoms,  will  very  certainly  lead  to  the  dis- 
covery of  the  simultaneous  existence  of  the  two  conditions.   For 
in  such  cases,  the  rational  signs  of  pregnancy  will  be  present,  or 
have  existed  in  fewer  or  greater  number;  such  as  the  suppression 
of  the  menses;  the  gradual  intumescence  of  the  lower  part  of  the 
abdomen;  morning  sickness  or  vomiting;  the  swelling  of  the 
mammae;  the  areola  round  the  nipple;  and  the  motion  of  the 
child,  will  all  serve  to  distinguish  the  two  conditions.    To  these 
we  might  add,  the  history  of  the  woman's  situation,  before  the 
swelling  made  its  appearance — for  the  absence  of  any  of  the  re- 
mote causes  of  dropsy  would  very  much  strengthen  the  case. 

3218.  Tympanites  can  rarely  be  mistaken  for  ascites,  by  one 
at  all  accustomed  to  sound  for  dropsy — authors  make  two  species 
of  tympanites ;  one  intestinal,  the  other  abdominal ;  but  it  is  only 
with  the  latter  that  ascites  can  be  confounded.     In  this  species, 
if  the  belly  be  struck  with  one  hand,  while  the  other,  (opened,) 
is  laid  flat  upon  the  abdomen,  no  fluctuation  will  be  perceived, 
and  the  stroke  will  yield  a  hollow,  or  cavernous  sound ;  while 
the  stroke,  in  ascites,  gives  a  dull  heavy  sound.     In  tympany, 
besides,  the  abdomen  is  tender  to  the  touch,  from  its  being  so 
violently  stretched ;  moreover,  the  tumour  is  elastic. 

Prognosis. 

3219.  This  will  generally  be  unfavourable  in  proportion  to 
the  extent,  nature,  and  duration  of  the  disease.  If  ascites  be  com- 
plicated with  anasarca,  or  hydrothorax,  the  chance  of  recovery 
is  small,  whatever  may  have  been  the  previous  strength  of  con- 
stitution; if  it  originate  from  visceral  obstruction,  the  chance  is 
still  less;  and  if  the  disease  has  been  of  long  standing,  and  no 


696  ASCITES. 

amendment  from  the  steady  use  of  well-directed  means;  if  the 
patient  have  been  enfeebled  before,  by  chronic  or  acute  disease; 
if  the  patient  be  old,  extremely  emaciated,  have  hectic,  aphthae, 
and  diarrhoea,  the  case  may  generally  be  looked  upon  as  hope- 
less. 

3220.  On  the  other  hand,  if  the  patient  be  young,  vigorous, 
and  until  now  healthy;  if  the  remedies  employed  against  his 
disease  act  favourably  upon  the  kidneys,  producing  copious  dis- 
charges of  urine ;  bowels  free,  and  the  stools  watery ;  the  skin 
soft;  fever  diminishing,  and  if  there  have  been  visceral  obstruc- 
tions, and  they  yielding;  complexion  improving;  thirst  abating; 
tongue  cleaning,  and  the  abdominal  tumour  subsiding,  we  look 
upon  the  chance  of  recovery  as  very  much  improving.   But  not- 
withstanding these  favourable  signs,  we  must  confess,  we  have 
seen  them  vanish,  and  this  at  a  moment  least  looked  for — we 
must  therefore  regard  dropsy  of  the  belly  always  as  a  disease  of 
danger. 

3221.  Perhaps  children  may  be  looked  upon  as  exceptions  to 
this  rule,  in  most  cases — we  have  seen  a  good  many  cases  of 
dropsy,  from  childhood  to  puberty;  and  we  do  not  recollect  but 
two  instances  of  death;  one  of  which  was  from  a  dropsy  conse- 
quent upon  scarlet  fever;  the  other  arose  from  a  stricture  in  the 
colon  in  a  boy  of  four  years  of  age — this  case  was  seen  by  my 
friends  Drs.  Physick  and  Randolph. 

Post  Mortem  Examinations. 

3222.  These  examinations  almost  constantly  prove,  either  the 
previous  existence  of  peritoneal  inflammation,  more  or  less  ex- 
tensive, or  the  disordered  state  of  the  several  abdominal  "viscera. 
The  liver,  the  spleen,  the  pancreas,  one  OB  all  are  found  enlarged, 
hardened,  tuberculated,  &c.     The  mesenteric  glands  are  almost 
constantly  found  enlarged,  and  hardened,  and  numerous  adhe- 
sions of  the  intestines  with  each  other,  or  with  the  peritoneum. 
The  kidneys  suffer  variously;  altered  in  size,  disorganized,  &c. 
The  heart  itself  does  not  escape;  and  as  a  consequence,  it  is  often 
found  diseased;  but  when  it  is  previously  diseased,  it  may  be- 
come also  a  cause  of  dropsy. 

Treatment  of  Acute  Jiscites.      , 

3223.  It  is  sufficiently  well  established  at  present,  that  there 
is  a  species  oi  dropsy,  which  is  attended  with  high  arterial  action, 
and  consequently,  requiring  antiphlogistic  remedies,  for  its  re- 
lief.    It  is  therefore  without  hesitation,  that  we  propose  blood- 
letting, as  a  valuable  remedy  in  this  disease.     By  this  remedy, 


ASCITES.  697 

very  important  purposes  are  fulfilled;  namely,  1st,  a  reduction 
of  arterial,  febrile  action;  2d,  an  abatement  of  local  inflamma- 
tion ;  and  3d,  it  insures  an  increase  of  activity  in  the  absorbent 
system.  The  two  first  of  these  advantages  will  be  readily  ad- 
mitted ;  while  the  third  may  surprise  some,  or  be  doubted  by 
others,  who  not  aware  of  the  fact,  that  absorption  never  goes  on 
so  rapidly,  as  when  the  blood-vessels  are  comparatively  empty. 

3224.  This  curious  physiological  fact,  is  of  great  practical  im- 
portance in  the  treatment  of  dropsy ;  and  however  reluctantly  it 
may  be  admitted  by  a  class  of  practitioners  who  always  treat 
dropsy  by  stimulants,  it  is  nevertheless  indisputable,  and  of  im- 
mense therapeutical  value.     We  therefore  do  not  hesitate  to  re- 
commend blood-letting,  in  the  treatment  of  one  species  of  this 
complaint.   This,  however,  is  no  new  practice;  on  the  contrary, 
we  believe  it  to  be  coeval  with  medical  record;  it  is  the  one,  by 
which  Botellus  acquired  so  much  reputation,  for  the  cure  of 
dropsy.  But  in  employing  venesection  for  the  cure  of  this  com- 
plaint, we  must  be  regulated  as  in  every  other  instance  of  dis- 
ease, by  the  condition  of  the  system — that  is,  we  must  part  with 
the  hypothesis,  that  dropsy  is  always  a  disease  of  weakness,  and 
that  the  excitement,  (which  cannot  fail  to  be  recognised,)  that  so 
often  accompanies  it,  is  accidental,  or  evanescent,  and  believe, 
that  the  pulse  when  high  in  dropsy,  requires  lowering,  as  much 
as  in  any  other  disease  in  which  this  state  exists.     Therefore, 
when  the  pulse  is  too  active,  it  must  be  reduced ;  but  only  then ; 
and  whenever  this  condition  is  renewed,  it  is  to  be  taken  down, 
again  and  again,  as  often  as  this  condition  recurs,  or  so  long  as 
it  may  continue.     But  on  the  other  hand,  if  this  do  not  exist, 
blood-letting  is  not  to  be  prescribed;  therefore,  the  pulse  should 
be  as  regularly  consulted,  and  its  indications  as  regularly  and  as 
implicitly  obeyed,  as  in  any  other  disease;  for  it  is  but  by  this 
means,  that  we  can  abstract  blood,  or  stimulate  with  any  cer- 
tainty or  advantage.     Bleeding,  however,  in  this  disease,  is  not 
to  be  exclusively  confined  to  general  abstraction ;  for  the  local, 
oftentimes  becomes  equally  important.     Therefore,  when  there 
is  local  pain,  or  general  soreness  in  the  abdomen,  much  advan- 
tage is  derived  from  leeching  or  cupping.  As  collateral  evidence 
of  the  utility  of  blood-letting  in  dropsy,  we  might  mention,  the 
immense  advantage  that  has  been  sometimes  derived  from  hsemor- 
rhagies,  either  spontaneous,  or  from  wounds;  and  as  corrobora- 
tive, though  weaker  evidence,  we  might  mention,  the  sizy  con- 
dition of  the  blood,  when  drawn  from  the  arm. 

Regimen. 

3225.  The  quality  of  the  food  should  be  made  to  conform  to 
the  general  indications  which  the  nature  of  the  disease  presents — 
in  the  active  dropsy,  an  antiphlogistic  regimen  should  be  ob- 

88 


698  ASCITES. 

served;  if  the  passive,  a  more  stimulating  diet  may  be  permitted. 
Dropsy  is  almost  always  attended  by  so  much  thirst,  as  to  make 
the  patient  clamorous  for  drink,  and  especially  water.  This  in- 
dulgence is  forbidden  for  the  most  part,  from  the  notion  that  the 
patient  "  has  already  had  too  much  water."  But  no  positive 
rule  can  be  laid  down  upon  this  subject,  as  we  may  imagine  cases 
where  it  might  be  proper  to  withhold  water  or  other  fluids ;  or 
at  least,  prevent  an  excessive  exhibition  of  it.  Dr.  Cullen  in- 
forms us  that  dropsies  have  been  cured  by  the  free  use  of  diluent 
drinks;  and  we  shall  presently  mention,  (par.  3236,)  the  case  of 
Gen.  Young,  who  appears  to  have  been  cured  of  an  inveterate 
dropsy,  by  large  draughts  of  cold  water.  We  have  never  wit- 
nessed any  injury  follow  a  reasonable  use  of  liquids  in  dropsy, 
and  we  therefore  do  not  prohibit  a  moderate  indulgence  in  any 
aqueous  drinks. 

Purging. 

3226.  We  believe  that  purging  is  resorted  to  by  all  practi- 
tioners, be  their  notions  of  the  nature  of  dropsy  what  they  may. 
This  is  an  important  practical  concession,  since  the  utility  of  this 
operation,  if  we  regard  the  welfare  of  the  patient,  must  not  be 
called  in  question.    They  not  only  promote  absorption,  but  sub- 
due fever,  and  remove  a  state  of  constipation,  that  is  highly  in- 
jurious.   In  declaring  this,  it  must  not  be  understood,  that  there 
is  no  choice  in  the  means  by  which  this  is  to  be  effected — on  the 
contrary,  much  depends  upon  a  proper  selection  of  the  articles 
for  this  purpose.     For  in  this  form  or  species  of  dropsy,  the 
drastic  articles  must  be  carefully  avoided  ;  such  as  the  elaterium, 
scammony,  colocynth,  croton  oil,  gamboge,  &c.  And  the  milder 
purgatives  be  had  recourse  to. 

3227.  The  cremor  tartar  and  jalap,*  answer  admirably  well ; 
magnesia  and  Epsom  salt,t  and  castor  oil,  in  ounce  doses,  are 
also  very  proper-;  and  even  the  common  neutral  salts  may  be 
employed  with  advantage,  as  they  are  very  sure  to  procure  co- 
pious watery  stools. 


*  R.  Crem.  Tart. 


Pulv.  Jalap  i      -         -         Jss. 


M.  div.  in  iij. 


Take  Cremor  Tartar  3  drachms. 

Powdered  Jalap          £  drachm. 
Mix  and  divide  in  three  parts. 


One  of  these  to  be  given  every  four  hours  until  they  operate  freely;  and  to  be 
repeated  as  occasion  may  require. 

Take  Calcined  magnesia  ~)  each  three 

Epsom  salt  >  drachms. 

Mix  and  divide  in  three  parts. 


f-  R.  Magnes.  alb.  ust  ?  ... 

Sulph.  Magnes.    5 


M.  div.  in.  iij. 

One  every  two  hours,  mixed  in  a  wine-glassful  of  lemonade  or  water,  until 
they  operate  freely;  to  be  repeated  as  occasion  may  require. 


ASCITES.  699 

Diuretics. 

3228.  We  are  obliged  to  have  recourse  to  these  remedies,  in 
alternation  with  purgatives,  or  even  sometimes  simultaneously. 
This  class  of  remedies  derive  their  efficacy  from  their  action  upon 
the  kidneys  and  absorbent  system. 

3229.  There  is  no  less  variety,  than  choice,  in  the  articles 
that  act  upon  the  kidneys;  but  unfortunately  the  selection  can- 
not be  made  with  as  much  certainty  as  from  among  the  cathar- 
tics— for  diuretics  are  by  no  means  so  constant  in  their  opera- 
tion upon  the  kidneys  as  would  be  desirable.     We  are  therefore 
often  under  the  necessity  of  changing  them— they  really  appear 
sometimes  to  deserve  the  character,  almost,  of  being  whimsical 
in  their  operations;  that  is,  they  will  perhaps  succeed  to-day,  and 
fail  to-morrow,  and  the  reverse.    Or  one  will  answer  for  a  time, 
and  then  cease  to  affect  the  kidneys  any  longer;  in  which  case,  we 
are  under  the  necessity  of  choosing  another,  and  sometimes,  an- 
other ;  but  fortunately  on  the  other  hand,  we  have  a  number  to 
select  from. 

3230.  In  the  inflammatory  or  acute  dropsy,  the  following  ap- 
pear to  answer  best;  cremor  tartar;*  soluble  tartar ;t  nitre;:}:  ace- 
tate of  potash;  and  scabious.§    All  the  tartrites  appear  to  possess 
very  decided  powers  over  the  urinary  organs,  and  should  alter- 
nately be  made  trial  of,  as  one  or  other  may  fail.     Nitrate  of 
potash  has  long  been  celebrated  for  its  diuretic  virtues,  as  well 
as  for  its  antiphlogistic    powers;    and    on    this   account   often 
merits  the  preference;  this  is  particularly  so,  where  there  is 
pretty  strong  evidence  of  active  inflammation  remaining.-    It 
however  carries  with  it  one  serious  objection  ;  it  very  frequently 
disagrees  with  the  stomach,  when   given  in  sufficiently  large 
doses.     We  generally  exhibit  it  as  directed,  for  chronic  rheuma- 
tism. 

3231.  Emetics  have  sometimes  been  employed  in  dropsy — 
we  have  never  used  them  ;  nor  can  we  learn  that  they  possess 
any  uncommon  efficacy. 

3232.  These  are  the  principal  remedies  in  the  active  state  of 
dropsy;  but  as  this  character  may  be  lost,  either  from  the  nature 
of  the  remote  cause;  or  from  bad  treatment;  or  from  peculiarity 
of  constitution,  it  will  be  necessary  to  give  an  account  of  the  re- 
medies, that  have  been  found  most  successful  in  this  passive  stage 
or  state  of  this  complaint.     This  species  must  be  determined  by 
the  state  of  the  pulse,  principally — in  this  case  it  will  be  found 
small,  rather  frequent,  and  soft.     There  will  be  no  febrile  and 
paroxysmal  movement,  unless  it  has  run  on  to  hectic.     There  is 

*  Super-tartras  potassae.  -j-  Potassac  tartras.  *  Potass*  nitras. 

§  Erigeron  philadelphicum. 


700  ASCITES. 

often  a  disposition  to  diarrhoea,  or  rather  a  frequent  inclination 
to  discharge  the  bowels ;  the  tongue  is  generally  clean  ;  thirst 
considerable  almost  always,  and  sometimes  intense  ;  no  tender- 
ness of  the  abdomen,  unless  pressed  very  hard;  urine  very  scanty, 
but  of  various  colours.  The  skin  dry  and  hard,  and  not  unfre- 
quently  cough,  of  considerable  frequency,  especially  on  first  lying 
down.  But  the  pulse  is  the  surest  guide. 

Purging. 

3233.  The  more  active  cathartics  appear  to  answer  best  in 
this  species  of  dropsy — indeed,  those  commonly  called  drastic 
are  usually  employed  ;  such  are  those  we  prohibited  in  the  active 
dropsy.     The  most  common  are  the  gamboge,  scammony,  elate- 
rium  or  the  elatin,  and  the  croton  oil. 

3234.  The  gamboge*  perhaps,  is  the  least  exceptionable,  as  it 
is  equally  active  as  the  other,  without  their  griping  property ; 
and  if  given  in  solution,  and  not  in  too  large  doses,  it  acts  with 
much  certainty  and  mildness.     The  scammony  is  active,  but  is 
very  apt  to  gripe;  and  has  no  one  advantage  over  the  gamboge — 
it  may  however  be  occasionally  resorted  to,  when  the  gamboge 
may  have  lost  its  effects.     Elaterium  and  elatin,t  are  more  dras- 
tic in  their  operations,  but  oftentimes  very  certain  in  carrying 
off  water  ;  they  act  sometimes  with  the  speed  of  the  trocar,  and 
more  rapidly  than  scarifications. 

3235.  Dr.  Physick  and  myself  attended  a  gentleman  labouring 

•  The  following  formula  was  communicated  to  me  by  Dr.  Alberti,  of  this 
city;  with  the  effects  of  which,  in  the  three  trials  I  have  made  with  it,  I  have 
had  great  reason  to  be  satisfied  with : — 


.  Gum.  guttac  gamb.  ^ij. 

Potassse  tartras  -        -        3J. 

Sacch.  alb.       -  zij. 

Aq.  font.          -  -        -        gvj. 

f.  sol. 


Take  Gamboge  -        2  scruples. 

Soluble  tartar  -        1  ounce. 

White  sugar  -        2  drachms. 
Water  6  ounces. 

Dissolve. 


Of  this  a  table-spoonful  is  to  be  taken,  every  two  or  three  hours  until  it  operate 
freely — to  be  continued  as  necessity  may  demand, 
f  The  elatin  is  generally  given  in.  the  form  of  pills — 


R.   Elatin  gr.  ss. 

Pulv.  rhaei          -        -        gr.  viij. 
Conserv.  rosar.  vel  syrup,  q.  s. 
M.  f.  pil.  viij. 


Take  Elatin  -        -        it  grain. 

Powdered  rhubarb         8  grains. 
Conserve  of  roses,  or  syrup,  suf- 
ficient to  make  into  8  pills. 


One  every  four  or  six  hours,  until  they  operate  sufficiently — to  be  repeated 
when  necessary.  Or  the  elatin  may  be  taken  in  combination  with  gamboge, 
as  follows: — 


R.  Pulv.  g.  guttac  gamb. 
Elatin 

Sp.  aether,  nitros. 
Aq.  font. 
M. 


Take  Powdered  gamboge  4  grains. 

Elatin  $  grain. 

Sweet  spirit  of  nitre  1  ounce. 

Water  4  ounces. 
Mix. 


A  table-spoonful  every  two  or  three  hours  until  it  purge  freely. 


ASCITES.  701 

under  universal  dropsy,  and  for  which  almost  every  cathartic  and 
diuretic,  had  been  tried  in  vain.  Dr.  P.  proposed  the  elatin ; 
and  a  sixteenth  of  a  grain,  was  ordered  once  in  four  hours.  The 
third  pill  operated  powerfully  by  the  bowels ;  and  continued  to 
do  so,  for  eight  and  forty  hours,  and  at  the  end  of  which  time, 
there  did  not  appear  to  be  left  in  any  part  of  the  body,  a  drop 
of  extravasated  fluid;  gallons  had  been  evacuated — every  un- 
pleasant symptom  had  yielded ;  the  patient  could  lie  flat  in  his 
bed ;  orthopnoea  was  removed ;  the  abdomen  flaccid,  and  the  ex- 
tremities emptied  of  water;  and  of  course  hope  was  entertained 
of  eventual  success;  but  alas!  all  this  improvement  was  but  tem- 
porary— every  part  again  began  to  fill,  nor  could  we  renew  the 
operation  of  the  medicine,  though  its  quantity  was  increased,  and 
the  periods  of  its  exhibition  shortened — the  patient  died  a  few 
days  after  in  great  suffering ;  indeed  there  was  almost  suffocation. 
Leave  could  not  be  obtained  to  examine  the  body. 

3236.  May  we  justly  or  not,  doubt  the  agency  of  the  elatin  in 
this  case,  because  subsequent  good  could  not  be  procured  from 
its  use?     Was  this  one  of  those  remarkable  coincidences,  where 
nature  achieved  the  good,  and  medicine  received  the  credit?    Is 
this  doubt  strengthened  by  the  case  of  General  Young,  in  whom 
"  shortly  after  drinking  freely  of  cold  water,"  (in  the  last  stage 
of  a  dropsy  for  which  he  had  been  tapped,)  "  a  determination  to 
the  kidneys  took  place,  succeeded  by  the  most  copious  urinary 
discharges ;  at  least  two  gallons  in  the  first  twenty-four  hours ;  and 
this  effect  continued  until  the  whole  water  was  completely  eva- 
cuated from  the  system?"  This  gentleman,  however  recovered.* 

3237.  Of  the  croton  oil,  we  can  say  nothing  in  dropsy — we 
have  tried  it  in  but  one  case;  in  this,  it  did  not  act  as  a  hydra- 
gogue,  though  exhibited  in  pnetty  free  doses — its  further  employ- 
ment was  suspended.     We  can  however  readily  believe,  it  will 
occasionally  answer  a  valuable  purpose. 

Diuretics. 

3238.  Contrary  to  all  reasoning,  the  most  valuable  diuretic  in 
this  species  of  dropsy,  is  the  digitalis;!  and  if  we  can  place  re- 

•  Appendix  to  Blackall  on  Dropsy,  p.  253. 

•j-  The  following  is  considered  a  good  form  for  the  exhibition  of  digitalis: — 


R.  Infus.  digital,  pur.  ' 

Acid,  tartar.  -         Qj. 

Carbon,  sodx  -         gr.  xxiv. 

Sp.  nitros.  aether.      -          ^j. 

Tinct.  scillse     -         -          gut.  iv. 

Aq.  menthse     -         -          5ij. 

M. 
This  quantity  to  be  taken  twice  or  thrice  a  day. 

t  The  infusion  of  digitalis  is  made  by  infusing  one  drachm  of  the  dry  leaves,  in  eight  ounces  of 
boiling  water  for  four  hours.    When  strained,  add  one  ounce  of  any  spirituous  water  to  preserve  it. 


Take  Infusion  of  foxglove  ^  ounce. 

Tartaric  acid        -  1  scruple. 

Carbonate  of  soda  24  grains. 

Sweet  spirit  of  nitre  1  drachm. 

Tincture  of  squills  4  drops. 

Mint  water  -  2  ounces. 

Mix. 


702  ASCITES. 

liance  upon  the  observations  of  others,  this  is  the  appropriate 
condition  to  display  its  immense  diuretic  properties.  As  re- 
gards our  own  experience,  we  have  little  to  say  in  its  favour. 
It  nevertheless  always  deserves  a  trial,  after  a  sufficient  reduc- 
tion of  the  system.  It  has  been  observed  however,  for  digitalis 
to  be  useful,  it  must  be  given  in  such  repeated  doses,  as  will  per- 
mit an  accumulation  of  it  in  the  system.  In  large  doses  its  effects 
are  transient,  besides  distressing  the  stomach  and  nervous  sys- 
tem excessively.  Of  the  squill  as  a  diuretic,  we  can  add  nothing 
new;  its  character  is  well  established  in  this  complaint;  but  per- 
haps more  especially  in  hydrothorax. 

3239.  The  guaiacum*  has  also  its  reputation  as  a  diuretic, 
and  as  a  hydragogue — of  this  medicine  we  can  say  much  that  is 
favourable  in  asthenic  dropsy,  and  especially  in  those  consequent 
upon  obstructed  catamenia,  without  fever;  indeed,  in  such  cases 
it  is  our  main  dependence,  and  it  rarely  disappoints.  We  there- 
fore recommend  it  with  considerable  confidence.! 


*  The  best  form  of  the  guaiacum  is  in  tincture — the  following  is  the  formula 
we  employ — it  differs  in  nothing  from  the  formula,  we  have  given  for  rheuma- 
tism, except  the  proportion  of  the  aq.  ammon.  purse  is  larger. 


.  Pulv.  g.  guaiac. 
Carbon,  sodx 
Pulv.  pimento 
Sp.  vin.  ten.    - 
Dig. 


Take  Powdered  guaiacum  4  ounces. 
Carbonate  of  soda      2  drachms. 
Powdered  allspice      1  ounce. 
Proof  spirit  1  pound. 

Digest. 


To  this  must  be  added  the  pure  ammoniated  water,  as  it  is  wanted,  in  the  pro- 
portion of  two  drachms  to  every  four  ounces  of  the  tincture — from  two  drachms 
to  half  an  ounce,  every  morning,  noon,  and  evening,  in  any  white  wine;  increas- 
ing the  dose  if  necessary,  until  it  operate  as  desired. 

f  Mr.  Van  Roosbroeck  of  Louvain,  in  a  letter  to  Broussais,  recommends  the 
use  of  nitrous  oxide  gas  for  the  cure  of  ascites. — "  The  first  patient  to  whom 
M.  Roosbroeck  administered  the  remedy,  was  a  man,  in  the  hospital  of  Louvain, 
fifty-two  years  of  age,  who,  for  two  years  and  a  half,  had  suffered  from  ascites, 
which  appeared  to  depend  upon  a  disease  of  the  heart,  on  account  of  the  ir- 
regularity and  intermittence  of  the  pulse,  and  the  obstructed  respiration  which 
had  been  present  from  the  commencement  of  the  disease.  For  two  years  all 
imaginable  means  had  been  tried  to  produce  the  absorption  of  the  fluid  effused 
in  the  abdomen.  Finally,  paracentesis  was  resorted  to,  but  which,  far  from  re- 
lieving the  disease,  seemed  to  augment  its  activity;  for  after  each  operation  the 
fluid  was  more  promptly  produced,  so  that  the  seventh  time,  twenty -four  hours 
after  the  operation,  the  abdomen  was  as  tense,  and  fluctuation  as  manifest  as 
before  the  operation.  If  paracentesis  was  longer  delayed,  the  extremities  and 
the  face  became  speedily  blue  and  infiltrated.  The  eighth  time  that  his  abdomen 
was  evacuated,  atmospheric  air  was  injected  into  the  cavity,  but  without  any 
effect.  Seeing  that  the  disease  had  for  two  years  resisted  all  remedies,  M. 
Roosbroeck  determined  to  inject  into  the  peritoneal  cavity  some  nitrous  oxide 
gas,  after  the  fluid  should  be  evacuated.  He  first  ascertained,  by  an  experi- 
ment upon  a  rabbit,  that  the  action  of  that  gas  upon  the  peritoneum  was  not 
injurious.  September  17th,  1830,  after  entirely  evacuating  the  fluid  from  the 
abdomen,  the  quantity  of  gas  produced  by  the  decomposition  of  two  drachms 
of  nitrate  of  ammonia,  was  collected  in  a  bladder,  and  injected  into  the  ab- 
domen through  the  cannula  of  the  trocar.  During  the  night  the  patient  was 
warm,  and  sweated  much,  which  had  not  happened  to  him  before  for  two  years; 


ANASARCA.  703 


SECT.  IV. — ANASARCA. 

3240.  There  are  two  varieties  of  dropsy  that  still  remain  to 
be  considered,  namely,  anasarca  and  redema. 

3241.  The  first  may  be  considered  as  a  dropsy  of  the  cellulai 
tissue  of  the  body,  but  particularly  evident  when  it  occupies  the 
stratum  immediately  under  the  skin.      It  is  characterized  by  a 
swelling  commencing  generally  in  tbe  feet  and  ankles ;  and  is 
especially  augmented  in  the  evening,  unless  the  patient  be  con- 
fined to  a  horizontal  position.    During  the  night  it  generally  dis- 
appears, but  resumes  its  position  during  the  day.     The  swelling 
is  soft  and  yielding,  retaining  the  impression  of  the  finger  for 
some  time. 

3242.  After  some  time  the  swelling  is  found  to  mount  upwards, 
and  eventually  to  spread  itself  over  the  whole  body ;  when  this 
happens,  much  inconvenience  is  experienced ;  the  action  of  the 
muscles  are  impeded,  giving  the  sensation  of  confinement.    The 
breathing  is  also  disturbed  in  some  severe  instances,  and  even 
cough  is  occasionally  provoked. 

3243.  The  bowels  for  the  most  part  are  constipated ;  the  urine 
high-coloured  and  scanty;  the  skin  dry,  and  usually  cold,,espe- 
cially  if  the  distention  be  considerable.     But  before  this  takes 
place,  it  frequently  is  warmer  than  natural,  and  particularly  to- 
wards evening;  the  tongue  is  white,  almost  always  pale,  and  thirst 
oftentimes  very  great. 

3244.  When  the  cause  of  anasarca  is  continued  for  some  time, 
and  the  serous  effusion  continue^  the  tumefaction  of  the  legs,  and 
more  particularly  the  upper  surface  of  the  foot,  becomes  enor- 
mously distended,  threatening  a  solution  of  the  continuity  of  the 
skin ;  before  this  happens,  however,  a  number  of  vesications 
filled  with  serum  make  their  appearance,  which  after  a  while 
discharge  themselves,  leaving  leakages  through  which  the  fluid 
in  the  cellular  membrane  discharges  itself.    This  takes  place,  we 
think,  most  commonly  where  there  are  mechanical  stoppages  to 

and  he  had  besides  passed  as  much  urine  as  he  usually  did  in  four  days;  but  he 
complained  of  some  pain  in  the  abdomen.  From  that  period  the  patient's  ab- 
domen did  not  increase  in  size;  it  became  even  smaller  than  the  day  after  the 
operation;  he  experienced  no  pain  in  it;  the  patient's  pulse,  however,  conti- 
nued irregular. 

"  M.  R.  has  tried  the  remedy  in  two  other  cases,  but  without  such  marked 
benefit;  copious  perspiration  and  urination  were,  however,  induced  by  it.  M. 
Broussais  has  also  employed  it  at  M.  R.'s  suggestion,  but  in  a  very  unpromising 
case;  no  injurious  effects,  however,  resulted  from  the  introduction  of  the  gas 
into  the  peritoneal  cavity.  The  remedy  seems  to  be  worth  a  further  trial. " — 
American  Journal  of  the  Medical  Sciences,  for  May,  1832,  from  the  Annales  de  la 
Mtdecine  P/iysiologique,  for  August,  1831. 


704  AN  AS  ARC  A. 

the  returning  venous  blood  from  the  extremities,  be  these  from 
pregnancy  or  visceral  enlargements. 

3245.  In  the  commencement  of  this  disease,  as  might  be  in- 
ferred from  what  has  been  said,  a  febrile  movement  of  the  sys- 
tem may  be  observed ;  at  other  times  this  does  not  take  place 
until  the  distention  of  the  skin  upon  the  feet  and  legs  is  very 
considerable,  and  threaten  erysipelatous  inflammation,  or  this  has 
actually  occurred. 

Causes. 

3246.  Anasarca  has  followed  from  a  variety  of  causes,  some 
of  which  are  sufficiently  obvious,  while  others  are  extremely 
obscure.     It  seems  in  many  instances  to  be  invited  from  what- 
ever will  suddenly  weaken  the  body,  as  hasmorrhagies,*  fevers, 
diarrhrea,  &c.;  particularly  if  errors  of  diet  have  been  committed, 
or  such  as  will  urge  the  arterial  system  to  unusual  action.     Sud- 
den checks  of  perspiration.     Certain  fevers,  as  scarlatina,  or 
measles;  it  is  also  produced  by  certain  gastric  irritations,  as  in 
urticaria,  and  from  the  exhibition  of  arsenic.     It  is  not  an  unfre- 
quent  sequel  to  the  habitual  and  inordinate  use  of  spirituous 
liquors ;  and  sometimes  the  consequence  in  females  of  uterine 
derangements,  as  amenorrhoea,  cancer  uteri,  &e. 

CEdema. 

3247.  (Edema  is  a  partial  anasarca,  and  may  be  confined  to 
the  limbs,  or  to  portions  of  them.     This  swelling,  like  anasarca, 
pits  upon  the  pressure  of  the  finger,  which  pit  remains  a  longer 
or  shorter  time ;  this  swelling  may  undergo  the  several  changes 
above  enumerated,  though  it  is  not  generally,  indeed  very  rarely, 
attended  by  fever. 

Causes. 

3248.  The  causes  may  be,  in  an  inferior  degree,  the  same  as 
for  anasarca ;  but  most  commonly  it  arises  from  mechanical  re- 

*  Anasarca,  or  dropsy,  are  frequently  the  consequences  of  profuse,  chronic 
haemorrhagies.  In  these  cases  the  circulating  fluid  is  but  little  more  than  se- 
rum, or  at  least  the  crassamentum  bears  but  a  small  proportion  to  it.  How 
shall  we  account  for  this  increased  effusion  or  diminished  absorption?  do  Dr. 
Parry's  views  explain  it?  He  says,  "when  dropsy  is  associated  with  large 
hsemorrhagies,  it  does  not  usually  accompany  them,  but  comes  on  after  they 
have  ceased;  and  I  have  concluded,  it  is  the  effect  of  the  fluids  taken  into  the 
stomach  being  absorbed  too  suddenly  for  the  relative  state  of  the  vessels, 
which  therefore  strive,  if  I  may  be  allowed  the  expression,  to  get  rid  of  it  by 
every  outlet." 


ANASAltCA.  705 

morae,  as  in  pregnancy,  from  ligatures,  swollen  glands  in  the 
groins  or  axillae,  and  also  from  paralysis.  When  this  happens, 
the  swellings  are  confined  to  the  affected  side. 

3249.  This  affection,  though  confessedly  dropsical,  is  not  ge- 
nerally dangerous,  and  perhaps  never  so,  but  when  the  causes 
which  have  produced  it  are  of  themselves  irremediable.     When 
it  complicates  ascites,  or  hydrothorax,  it  must  be  looked  upon 
but  as  a  symptom  consequent  upon  a  hydropic  diathesis,  which, 
if  incurable,  so  will  be  anasarca,  generally  speaking.     We  say 
generally,  for  this  is  not  constantly  so.  Dr.  Chapman,  Dr.  Hays, 
and  myself,  attended  a  gentleman  from  whom  every  vestige  of 
anasarca  was  removed,  though  he  died  of  visceral  obstructions, 
producing  effusions  in  the  abdomen  and  thorax.     (Edema,  we 
believe,  is  never  dangerous  in  itself,  and  seldom  from  any  cause, 
unless  gangrene  supervene. 

3250.  From  what  has  been  said  on  hydrothorax,  we  must  re- 
ceive with  some  caution  the  oedematous  swelling  of  the  feet  and 
legs,  as  a  symptom  of  this  affection.     Nor  must  we  look  upon  it 
as  an  unpromising  symptom,  even  when  excessive,  during  preg- 
nancy, as  it  almost  always  subsides  a  few  days  before  labour,  or 
very  soon  after. 

Treatment. 

3251.  The  treatment  of  anasarca  and  oedema  is  so  analogous 
to  that  of  the  other  dropsies,  that  it  requires  no  additional  obser- 
vations upon  this  point;  for  like  dropsy  it  must  be  treated  ac- 
cordingly as  it  may  be  idiopathic  and  acute,  or  as  symptomatic 
and  chronic.     But  like  ascites,  it  may  require  tapping — the  pro- 
priety of  this  is  disputed  by  some,  but  not  upon  sufficient  grounds. 
For  we  are  persuaded  much  less  mischief  is  likely  to  follow  a 
few  distant  punctures  with  the  point  of  a  very  sharp  lancet,  than 
from  permitting  the  distention  to  go  on  to  bursting.    When  this 
is  allowed,  the  most  extensive  and  serious  mischief  sometimes 
arises,  which  we  have  never  witnessed  when  punctures  have 
been  early  and  judiciously  made.     We  say  early ;  by  this  we 
mean  before  the  skin  has  almost  lost  its  life;  and  when  we  find 
that  the  remedies  we  are  employing  do  not  prevent  the  further 
accumulation  of  serum.     In  a  number  of  instances  of  anasarca, 
attended  by  excessive  distention,  we  have  seen  the  happiest  re- 
gults  follow  the  puncturing  of  the  most  tumid  parts. 

89 


706  H.ZEMORRHAGIES. 

CHAPTER  XIV. 

H^EMORRHAGIES. 

3252.  DR.  CULLEN  has  divided  haemorrhagies  into  active,  and 
into  what  he  calls  "a  well-founded  distinction,"  passive.     He 
thinks  fever  essential  to  the  first  variety,  and  its  absence  to  the 
second.  We  have  no  hesitation  to  admit,  that  hsemorrhagies  may 
exist  with  either  of  these  conditions  of  the  system  ;  provided  this 
concession  be  not  construed  into  the  admission  of  one  of  Dr. 
Cullen's  distinctions  of  haemorrhagies;  that  is,  the  passive;  this  it 
is  said  is  owing  to  the  weakness  or  want  of  power  in  the  blood- 
vessels to  retain  their  contents — a  kind  of  leakage  of  blood  from, 
the  patulous  mouths  of  the  blood-vessels ;  and  therefore  takes 
place,  without  any  increase  of  action  of  the  vessels  that  pour  out 
this  fluid. 

3253.  To  this  doctrine   Broussais  demands,   "  if  this  were 
really  the  cause  of  hemorrhage,  why  does  it  not  always  take 
place  in  the  last  moments  of  existence,  where  weakness,  (asthenie,) 
is  at  its  height;  and  why  does  not  the  whole  mass  of  blood  then 
discharge  itself  by  the  capillaries  of  the  body  ?  Now  do  we  not 
observe  on  the  contrary,  that  petechias  become  pale  as  death  ap- 
proaches?  For  in  this  terrible  moment,  the  contraction  of  the 
exterior  capillaries  drive  back  all  the  fluids  to  the  interior  vis- 
cera."* 

3254.  Dr.  Caldwell  makes  the  following  pertinent  observa- 
tions on  the  "passive  haemorrhagy,"  in  a  note  on  this  chapter 
in  his  edition  of  Cullen's  Practice,  Vol.  I.  p.  426.     "The  divi- 
sion of  hasmorrhagies  into  '  active  and  passive,'  recognised  by 
our  author  in  this  article,  is  utterly  unfounded,  and  ought  to  be 
rejected  from  pathological  science.     The  phraseology  leads  to  a 
physiological  error.     The  expression  '  passive  haemorrhagy,'  as 
applied  to  living  matter,  is  a  gross  misnomer.     During  life,  no 
haemorrhagy  can  possibly  be  passive.  Blood  flows  from  the  ves- 
sel that  contains  it,  at  least  in  part,  by  means  of  the  action  of 
that  vessel.   Nor  is  it  possible  for  such  action  to  cease,  otherwise 
than  by  the  cessation  of  life  in  that  part.     But  the  cessation  of 
life  is  the  commencement  of  gangrene.     A  haemorrhagy  really 
passive,  therefore,  cannot  take  place  except  from   gangrenous 
vessels.  But  from  such  vessels,  unless  they  be  very  large,  blood 

•  Examen  des  Doctrines  Med.  p.  128. 


HJEMORRHAGIES.  707 

does  not  flow  at  all.  The  reason  is  obvious.  They  act  on  the 
blood  which  they  contain  like  dead  matter,  and  we  well  know 
that  the  action  of  dead  matter  on  blood  forces  it  to  coagulate. 
Hence,  in  the  vessels  of  a  gangrenous  part,  the  blood  does  co- 
agulate, and  prevents  the  haemorrhagy  that  would  otherwise 
ensue.'7 

3255.  "  Every  haemorrhagy,  therefore,  that  does  or  can  take 
place  from  the  living  body,  is  really  an  active  one.  It  arises  not 
from  the  absolute  want  of  action  in  the  part,  but  from  its  wrong 
action.  The  vessels  dilate^  or  rather  contract  and  dilate  alter- 
nately, when  they  ought  to  contract  only,  and  thus  prevent  the 
escape  of  the  blood  they  contain." 

3256.  In  asthenic  diseases  when  attended  by  haemorrhage,  and 
in  which  there  might  be  a  plausible  pretext  for  the  supposition 
that  they  depended  upon  debility  or  a  loss  of  power,  Broussais 
says,  in  such  cases  "we  may  ask  where  resides  the  force  that 
thus  overcomes  the  resistance  of  the  sanguineous  capillaries; 
shall  we  place  it  in  the  heart?  No,  for  this  is  struck,  according 
to  Brown,  with  profound  asthenia.    May  it  reside  in  the  blood? 
No,  for  this  would  be  to  suppose  it  possessed  an  action  indepen- 
dent of  the  vessels  which  contain  it."  p.  129.*  We  cannot  there- 
fore adopt  the  opinion,  that  there  is  an  haemorrhage  independent 
of  the  action  of  the  blood-vessels. 

3257.  Notwithstanding  we  cannot  yield  to  this  division  of 
Cullen  and  others,  we  are  nevertheless  perfectly  convinced,  that 
there  is  a  "pyrectic,  and  an  apyrectic"  haemorrhage,  (to  adopt  the 
terms  of  Dr.  Caldwell,)  and  which  will  necessarily  require  a  mo- 
dification of  treatment,  though  they  are  virtually  the  same,  as 
regards  the  local  action,  t 

3258.  As  we  know  no  histories  of  symptoms  more  faithful 
than  those  of  Cullen,  in  the  general,  we  shall  very  much  adhere 
to  them ;  reserving  to  ourselves  the  right  to  differ  with  him, 
should  any  occasion  occur  in  which  we  should  judge  this  ne- 
cessary. 

*  He  therefore  lays  it  down  as  an  axiom,  "  toutes  les  h£morrbagies  qui  ne 
dependent  pas  d'une  violence  exte"riure  et  qui  sont  spontane'es,  sont  actives, 
quelle  que  soit  la  faiblesse  du  sujet." — Examen.  des  Doct.  Med.  Prop,  cxcviii. 

f  "  The  local  phenomena  are  of  a  similar  character,  whether  the  flow  of 
blood  be,  or  be  not,  accompanied  with  febrile  symptoms;  the  part  which  is  the 
seat  of  the  haemorrhage,  continues  still  to  possess  increased  heat  and  redness, 
excepting,  that  after  the  discharge  of  blood  has  continued  for  a  certain  time, 
the  local  symptoms  diminish  of  course,  in  intensity." — Condie  on  Haemorrhages, 
North  Am.  Journ.  Vol.  3d,  p.  252.  To  which  we  have  much  pleasure  in  re- 
ferring the  reader,  for  a  complete  refutation  of  the  doctrine  of  passive  haemor- 
rhage, and  also  a  clear  and  satisfactory  exposition  of  the  doctrines  of  many  of 
the  late  and  present  French  pathologists,  upon  this  intricate  and  interesting 
subject. 


708  HJEMORRHAGIES. 


Phenomena  of  Hsemorrhagy. 

3259.  Haemorrhagies  are  most  common  in  plethoric  habits^ 
and  in  the  sanguine  temperament.     They  are  besides  more  fre- 
quent in  the  spring,  or  in  the  beginning  of  summer.   Sometimes 
these  discharges  are  preceded  by  symptoms,  which  declare  them 
about  to  take  place — as  a  sense  of  tension  or  fulness  in  the  part 
from  whence  the  blood  is  about  to  flow.    A  swelling,  some  red- 
ness, and  sense  of  heat  or  itching,  have  been  sometimes  observed 
in  parts  which  come  under  our  view.     A  sense  of  weight  and 
heat,  and  various  pains,  have  been  experienced,  when  it  is  an 
internal  part  that  is  the  seat  of  the  hsemorrhagy.     To  these  may 
be  added  a  stage  of  pyrexia,  during  which  time,  blood  of  a  florid 
colour  flows  in  a  greater  or  lesser  quantity,  and  for  a  longer  or 
shorter  time,  but  generally  until  the  pyrexia  itself  ceases. 

3260.  During  this  time,  the  pulse  is  frequent,  quick,  full,  and 
often  hard;  but,  these  conditions  will  diminish  as  the  blood  flows. 
Blood  drawn  at  this  time,  shows  the  inflammatory  crust.     Hae- 
morrhagies from  internal  causes,  are  apt  to  repeat  themselves,  at 
certain  intervals  or  at  stated  periods;  but  we  have  never  had 
sufficient  cause  to  believe  in  the  agency  of  the  moon  to  produce 
these  phenomena.     Dr.  Cullen  does  not  appear  to  have  been  ac- 
quainted with  the  intimate  relationship  between  hemorrhage  and 
inflammation,  though  he  declares  "  there  are-  purely  topical  hae- 
morrhagies,  as  there  are  purely  topical  inflammations ;"  Bichat 
however  and  others,  have  most  satisfactorily  traced  their  analo- 
gies. We  shall  not  stop  to  inquire  into  the  truth  of  Dr.  Cullen's 
ingenious  speculations  on  the   "Proximate  Cause  of  Haemor- 
rhage;" we  shall  merely  observe,  that  he  has  admitted  every 
phenomena  that  would  be  required,  by  the  modern  pathologist, 
in  the  active  hasmorrhagies ;  and  we  believe,  that  had  he  lived 
to  have  examined  the  present  reasonings  and  proofs  against  the 
passive,  he  would  have  cheerfully  given  them  up.   And  we  shall 
only  add  further,  that  modern  research,  both  faithfully  and  ably 
conducted,  have  never  yet  detected  any  lesion  in  the  vessels  from 
which  the  blood  escaped. 

Proximate  Cause. 

3261.  Chomel  says,  "there  remains  in  the  present  state  of  our 
science,  but  one  mode  of  explaining  the  effusion  of  blood;  it  can 
take  place  only  through  the  vessels  which  pour  out  the  mucus, 
the  serum,  &c,  on  the  surface  of  the  different  mucous,  serous, 
and  other  tissues — vessels,  the  existence  of  which  cannot  be 


HJEMORRHAGIES.  709 

doubted,  though  we  are  ignorant  of  their  structure  and  arrange- 
ment."*! 

Remote  Causes. 

3262.  Broussais  declares  the  "remote  causes  of  spontaneous 
haemorrhagies  to  be  the  same  as  those  of  inflammation."     Dr. 
Cullen  says  they  are  external  heat;  a  diminution  of  atmospheric 
pressure;  whatever  increases  the  force  of  the  circulation,  as  bo- 
dily exertion  or  mental  agitation;  violent  exercise  of  particular 
parts  of  the  body,  provided  such  parts  "are  already  affected  with 
congestions,  or  liable  to  them;"  postures  of  the  body  increasing 
determinations,  or  ligatures  occasioning  accumulations  of  the 
blood  in  particular  parts  of  the  body  ;  a  determination  into  cer- 
tain vessels  rendered  habitual  by  the  frequent  repetition  of  hae- 
morrhagy  from  them ;  cold,  externally  applied,  as  changing  the 
distribution  of  the  blood ;  full  feeding,  and  the  too  free  use  of 
spirituous  liquors;  suppression  of  customary  evacuations;  pecu- 
liarities of  constitution  transmitted  from  parent  to  child.f 

3263.  "In  all  cases  of  haemorrhage,  two  conditions  of  the 
capillary  and  exhalant  systems  may  be  remarked.    First)  In  the 

*  Condie  on  Hxm.  loc.  cit. 

f  Broussais  says,  "les  hsemorrhagies  spontanee  dependent  d'une  irritation 
des  capillaries  sanguins." — Prop.  cc. 

+  There  are  sufficient  grounds  to  believe,  that  "  a  peculiarity  of  constitution 
can  be  transmitted  from  parent  to  child,"  and  may  be  considered,  as  a  legiti- 
mate remote  cause,  of  hasmorrhagy.  Besides  the  cases  related  by  Dr.  Otto  and 
X)thers,  Dr.  Chapman  and  myself  attended  a  young  lady  sixteen  years  old,  of 
delicate  habit,  for  menorrhagia.  She  had  had  previously  to  this  attack  of  hae- 
morrhage, a  long-continued  bleeding  from  the  nose,  from  which  she  was  re- 
lieved, after  a  long  time,  and  much  difficulty,  by  severe  dieting  and  repeated 
purgings.  After  the  epistaxis  was  relieved,  the  catamenia  began  to  show  them- 
selves, and  continued  for  nearly  a  year  with  considerable  regularity,  but  always 
pretty  free.  She,  however,  during  this  time,  would  occasionally  throw  up  blood 
from  the  lungs  on  first  waking  in  the  morning,  accompanied  by  a  slight  cough. 
About  the  beginning  of  October,  1829,  her  menstrual  discharge  appeared,  and 
continued  without  abatement  for  a  month.  At  this  time,  I  was  called  upon  to 
prescribe  for  her.  The  usual  remedies  were  employed,  and  the  common  re- 
strictions were  closely  adhered  to  for  a  fortnight,  without  benefit.  The  patient's 
strength  was  rapidly  declining,  and  the  haemorrhage  from  the  uterus  as  abun- 
dant as  ever.  A  variety  of  other  remedies  were  now  tried,  which  eventually 
succeeded  in  stopping  the  discharge,  and  the  patient  recovered  her  strength 
rapidly.  In  this  case,  purging,  very  low  diet,  rest,  blood-letting,  leeching, 
blistering,  sinapisms,  acetate  of  lead,  an  emetic,  the  spirit  of  turpentine,  ex- 
tract of  rhatany,  Dover's  powder,  nitre  and  the  tampon, 'were  employed  in 
turn.  The  tampon  was  the  only  remedy  which  gave  a  check  to  the  bleeding; 
but  immediately  after  this  was  arrested,  a  discharge  from  the  lungs  took  place, 
the  nitre  was  continued  in  fifteen  grain  doses  every  two  hours  for  three  days; 
at  the  end  of  this  time,  the  uterine  discharge  ceased,  as  did  that  from  the  lungs. 
The  father  of  this  young  lady,  and  some  others  of  his  family,  had  the  haemor- 
rhagic  constitution;  and  it  was  transmitted  and  perpetuated  in  a  certain  degree, 
to  their  offspring. 


710  H^MORRHAGIES. 

capillaries  an  unusual  proportion  of  blood  is  accumulated,  so  that 
the  small  ones  conveying  red  hlood  become  large  and  distended, 
and  those  conveying  the  colourless  part  are  injected  with  red 
blood.  Secondly,  After  this  state  has  continued  for  some  time, 
red  blood  is  observed  to  ooze  in  minute  drops  from  the  surface 
of  the  membrane,  and  progressively  to  increase  in  quantity  and 
superficial  extent.  The  cause  of  this  accumulation  and  consequent 
exudation  is  not  known.  To  assert  as  Bichat  has  done,  that  a 
change  in  the  organic  sensibility  of  the  exhalants  opens  a  passage 
through  them  to  red  unchanged  blood,  is  to  describe  the  fact  in 
a  different  mode,  without  explaining  the  reason.  The  hsemor- 
rhagic  effort  of  Stahl  and  the  error  loci  of  Boerhaave,  are  equally 
true  and  not  less  intelligible." — Craigie,  Elem.  of  Gen.  Path. 
Jlnat.  p.  209. 

Treatment  of  Hsemorrhagy. 

3264.  Dr.  Cullen  says,  "  in  entering  upon  this  subject,  the  first 
question  which  presents  itself  is,  whether  the  cure  of  haemorrha- 
gies  ought  to  be  attempted  by  art,  or  if  they  should  be  left  to  the 
conduct  of  nature  ?"  "  This  latter  opinion,"  he  continues,  "  was 
the  favourite  doctrine  of  the  celebrated  Dr.  Stahl  and  his  fol- 
lowers."    Upon  a  due  consideration  of  the  subject,  Dr.  Cullen 
very  properly  concludes,  "that  haemorrhagy,  either  upon  its 
first  attack,  or  upon  its  first  recurrence,  is  never  necessary  to  the 
health  of  the  body,  excepting  upon  the  supposition  that  the  ple- 
thoric state  which  seems  to  require  the  evacuation,  cannot  be 
otherwise  prevented  or  removed;  and  as  I  imagine  it  possible  by 
other  means  to  prevent  or  remove  a  plethoric  state,  so  I  do  not 
think  that  haemorrhagy  is,  in  all  cases,  necessary.     In  general  I 
am  of  opinion  that  hsemorrhagy  is  to  be  avoided." 

3265.  1.  "Because  it  does  not  always  happen  in  parts  where 
it  is  safe." 

3266.  2.  "Because  often,  while  it  does  relieve  a  plethoric 
state,  it  may  at  the  same  time  induce  a  dangerous  disease." 

3267.  3.  "Because-  it  may  often  go  to  excess,  and  either  en- 
danger life  or  induce  a  dangerous  infirmity." 

3268.  "And  lastly,  because  it  has  a  tendency  to  increase  the 
plethoric  state  it  was  meant  to  relieve;  to  occasion  its  own  re- 
currence, and  thereby  induce  a  habit  which,  if  left  to  the  preca- 
rious and  unequal  operation  of  nature,  may,  from  the  frequent 
errors  of  this,  be  attended  with  much  danger.     It  is  further  to  be 
considered,  that  haemorrhagies  do  not  always  arise  from  the  ne- 
cessities of  the  system,  but  often  proceed  from  incidental  causes. 
It  appears  to  me  that  all  hsemorrhagies  of  this  kind  may  be  im- 
mediately suppressed."  "  I  conclude,  that  every  preternatural 


H.2EMORRHAGIES.  711 

haemorrhagy,  or  in  other  words,  every  one  except  that  of  the 
menses  of  females,  is  to  be  avoided." 

3269.  This  last  opinion  is,  however,  to  be  received  with  con- 
siderable caution,  in    certain    habitual  discharges  of  blood,  as 
haemorrhoids,  and  epistaxis  when  it  has  been  of  long  standing, 
and  especially  when  preceded  by  head-ache  or  other  inconve- 
nience.   The  same  may  be  said  of  the  occasional  return  of  the 
catamenia,  after  they  have  ceased  to  appear  as  a  regular  elimina- 
tion in  women  disposed  to  cancerous  and  some  other  affections 
of  the  uterus. 

3270.  In  the  treatment  of  haemorrhagy,  the  pulse  is  to  be  con- 
stantly consulted,  as  upon  its  condition  important  decisions  are 
to  be  made,  as  to  the  nature  of  the  remedies  to  be  employed ;  we 
shall  therefore  consider  the  principal  indications  to  be  fulfilled  in 
the  attempt  to  prevent  the  return  of  this  disease.    The  most  im- 
portant necessarily  are,  the  prevention,  and  the  removal  of  ple- 
thora.    This  is  to  be  effected  by — 1.  Diet.     2.  Bleeding.     3. 
Purging.     4.  Avoiding  the  remote  caus,es. 

1.  Diet. 

3271.  It  must  be  evident,  that  attention  to  the  ingesta  is  ab- 
solutely necessary,  if  we  mean  to  diminish  the  plethoric  condi- 
tion of  the  system.    This  end  is  to  be  answered,  first,  by  the  na- 
ture of  the  aliment;  second,  the  quantity. 

3272.  The  nature  of  the  aliment  may  be  either  animal  or  ve- 
getable.    Of  the  first,  none  should  be  taken,  so  long  as  a  hsemor- 
rhagic  disposition  of  the  system  displays  itself.    To  the  second, 
the  patient  should  be  absolutely  confined.    As  regards  quantity, 
it  will  be  necessary  to  observe  the  effects  of  that  which  is  ordi- 
narily taken  ;  and  if  this  produce  too  much  fulness,  the  quantity 
must  be  abated,  or  a  less  succulent  kind  substituted.  Nothing  but 
water  should  be  drank. 

2.  Bleeding. 

3273.  This,  as  an  habitual  remedy,  should  be  used  with  great 
caution,  lest  it  unnecessarily  debilitate,  or  produce  a  disposition 
to  plethora.    The  pulse  should  therefore  be  the  guide ;  and  if  the 
tendency  to  make  too  much  blood  cannot  be  conquered  by  a 
strict  attention  to  regimen,  it  must  occasionally  be  employed. 
This  sometimes  becomes  particularly  important  in  such  cases  as 
assume,  to  a  greater  or  lesser  extent,  a  periodical  movement, 
preceded  by  signs,  that  announce  the  discharge  about  to  take 
place.    Here  the  loss  of  a  few  ounces  of  blood  may  interrupt  the 
renewal  of  the  hemorrhage.     But  let  it  be  remembered  in  em- 


712  UJEMORRHAGIES. 

ploying  this  remedy,  that  an  excessive  quantity  should  never  be 
taken — indeed  no  more  than  will  lower  in  a  moderate  degree  the 
force  of  the  pulse.  For  when  this  is  effected,  even  in  a  moderate 
degree,  it  often  proves  successful  in  preventing  a  renewal  of  the 
discharge,  as  it  requires  a  certain  force  of  arterial  action  to  pro- 
duce hasmorrhagy  ;  therefore,  if  the  pulse  be  lowered,  even  in  a 
moderate  degree,  it  may  prevent  the  discharge  from  taking  place, 
as  certainly  as  if  a  larger  quantity  were  drawn ;  for  hoemorrhagy 
depends  less  upon  the  absolute  quantity  of  bloody  than  upon  the 
vigour  or  peculiarity  of  the  circulation. 

3.  Purging. 

3274.  This  is  a  very  efficient  means,  if  properly  pursued,  in 
preventing  hjemorrhagy,  especially  bleeding  from  the  nose.  The 
influence  of  this  operation  upon  determinations  of  blood  to  the 
head,  has  always  been  acknowledged ;  and  it  is  every  way  pro- 
per that  we  take  advantage  of  this  fact  in  the  treatment  of  this 
disease.  By  recommending,  however,  this  mode  of  depletion, 
we  must  not  be  misunderstood ;  an  excess  is  not  meant — by 
purging  in  this  instance,  we  only  mean  regular,  but  never  very 
frequent  discharges  from  the  bowels.  Three  evacuations  per 
diem,  are  every  way  sufficient,  provided  they  are  loose  or  wa- 
tery. To  secure  these  qualities,  a  proper  choice  of  the  purgative 
must  be  made,  as  all  have  not  this  desirable  effect.  Any  of  the 
neutral  salts  answer  the  purpose  claimed,  admirably,  when  they 
sit  well  upon  the  stomach ;  and  this  they  usually  do.  We  are  in 
the  habit  of  having  four  ounces  of  the  sulphate  of  magnesia  dis- 
solved in  a  pound  and  an  half  of  water — a  wine-glassful  of  this  is 
ordered  every  morning  to  an  adult,  and  half  this  quantity  to 
younger  subjects;  if  it  operate  too  much,  we  cause  the  quantity 
to  be  diminished ;  if  it  do  not  act  sufficiently,  the  dose  must  be 
increased.  Cream  of  tartar  and  jalap  are  also  very  certain  and 
very  kind  in  their  operation,  and  may  be  given  in  fifteen  grain 
doses  of  each,  every  third  day,  mixed  in  a  little  thin  syrup;  the 
dose  to  be  increased  or  diminished  as  circumstances  may  require. 

4.  ^Avoiding  the  Remote  Causes. 

3275.  The  importance  of  this  rule  is  self-evident,  and  is  never 
to  be  lost  sight  of  in  the  treatment  of  haemorrhagy,  when  it  is 
practicable  to  comply  with  the  injunction.    It  will  almost  neces- 
sarily be  in  the  power  of  every  individual,  however,  to  shun 
some  of  those  enumerated  above,  (par.  3262,)  and  as  many  as 
can  be  avoided,  should  be. 

3276.  In  the  treatment  of  hsemorrhagy,  it  is  of  great  conse- 


EPISTAXIS.  713 

quence  to  equalize  the  circulation  aa  much  as  possible ;  and  for 
this  purpose  there  is  nothing  so  good  as  well-conducted  exercise. 
Of  the  several  exercises  within  our  choice,  that  of  walking  is 
certainly  the  best — it  gives  equal  employment  to  all  the  muscles 
of  the  body,  and  by  this  means  determines  an  equal  distribution 
of  the  blood.  It  should  not,  however,  be  carried  to  excess — for 
we  must  insist  that  exercise  is  medicine,  and  should  be  used  with 
caution  and  discretion;  for  over-exertion  is  even  more  injurious 
than  a  deficiency  of  it.  It  should  be  so  calculated  as  to  diffuse 
the  blood  with  regularity,  to  dispose  the  skin  to  become  soft,  but 
never  to  hurry  the  respiration  beyond  a  pleasurable  degree. 

3277.  As  there  is  a  considerable  tendency  in  all  haemorrhagies 
for  the  circulation  to  be  unequal,  and  especially  in  the  lower  ex- 
tremities, much  care  should  be  taken  to  guard  against  cold  feet  and 
legs — to  prevent  or  overcome  this,  all  cold  and  damp  to  the  feet 
should  be  avoided  as  much  as  possible;  and  if  the  feet  are  habi- 
tually cold,  or  become  so  on  slight  occasions,  the  mustard  bath 
should  be  resorted  to,  two  or  three  times  a  week.*  Flannel  next 
the  skin  is  also  an  important  application. 

3278.  We  shall  detail  the  treatment  necessary  during  the  con- 
tinuance of  the  bleeding,  under  the  heads  of  the  respective  hae- 
morrhagies. 

SECT.  I. — EPISTAXIS,  OR  BLEEDING  FROM  THE  NOSE. 

3279.  The  exposed  situation  of  the  vessels  of  the  membrane 
which  lines  the  nostrils,  renders  them  very  liable  to  hsemor- 
rhagy;  since  they  have  nothing  to  support  the  external  surface, 
of  an  extremely  delicate  membrane. 

3280.  This  hamorrhagy  is  most  frequent  in  the  early  part  ef 
life,  as  sanguineous  determination  is  most  vigorous  at  this  time; 
it  may  however  take  place  at  a  later  period,  though  it  is  not  so 
common.     In  boys  and  girls,  the  time  of  puberty  is  the  most 
common ;  it  is  however  observed  occasionally,  both  sooner  and 
later ;  it  rarely  happens  in  advanced  life. 

3281.  The  blood  generally  issues  from  but  one  nostril  at  a 
time,  though  we  have  now  and  then  seen  it  flow  abundantly  from 
both,  when  the  haemorrhage  has  been  of  the  spontaneous  kind, 
or  when  produced  by  external  violence.     It  may  take  place  in 
persons  of  every  temperament  and  constitution ;  but  it  is  most 
common  to  the  sanguine,  and  those  disposed  to  plethora. 

*  A  gallon  of  warm  water,  and  two  or  three  table-spoonfuls  of  the  flour  of 
mustard,  form  the  mustard  bath.  It  is  to  be  used  the  last  moment  before  going 
to  bed.  The  feet  and  legs  should  be  rubbed  in  the  bath  until  they  glow,  and 
wiped  dry  before  getting  into  bed. 

90 


714  EPISTAXIS. 

3282.  This  discharge  is  almost  always  announced,  by  a  sense 
of  fulness,  or  heaviness  in  the  forehead,  head-ache,  redness  of 
the  eyes,  flushing,  beating  of  the  carotids,  and  temporal  arteries, 
and  an  uneasy  sensation  or  itching  in  the  nostril;  costiveness, 
cold  feet,  and  a  sensation  of  chilliness.   The  quantity  discharged 
does  not  always  correspond  with  the  excitement  of  the  system; 
especially,  where  the  haemorrhagy  has  been  often  repeated ;  for 
under  these  circumstances,  the  part  concerned  becomes  liable  to 
partial  accumulation  or  congestion,  and  will  readily  yield  its 
blood,  without  perhaps  any  general  febrile  movement. 

3283.  In  some  instances  of  epistaxis,  the  system  at  large,  or 
portions  of  it,  as  the  head,  seem  very  much  more  relieved  of 
uneasy  sensations  by  the  loss  of  comparatively  a  small  quantity 
of  blood,  than  if  a  much  larger  quantity  were  drawn  from  the 
arm;  and  this  has  given  rise  to  a  comparison  very  much  in  favour 
of  the  spontaneous  efforts  of  the  system  to  relieve  itself,  over  the 
means  resorted  to  by  art.    This  fact  is  not  to  be  disputed  ;  but  it 
does  not  prove  what  is  intended  to  be  proved;  for  in  the  instances 
in  which  this  relief  is  afforded,  there  is  always  a  partial  engorge- 
ment, giving  rise  to  these  unpleasant  feelings;  consequently,  in 
such  cases  the  affection  is  always  local  in  the  first  instance,  but 
with  which  the  system  at  large  will  soon  sympathize,  provided 
the  irritation  be  considerable  or  sufficiently  long  continued.     It 
would  therefore  follow,  that  relief  is  experienced  as  soon  as  the 
local  disturbance  is  removed — the  same  thing  happens  in  many 
other  cases,  from  the  partial  discharge  of  blood,  as  from  the  ap- 
plication of  leeches,  or  cupping-glasses;  and  which  proves  that 
the  removal  of  the  congestion  is  often  all  that  is  necessary  to- 
wards relief;  and  that  the  spontaneous  effusion  from  the  nose,  or 
the  abstraction  of  blood  from  other  parts  of  the  body  similarly 
circumstanced,  by  leeches  or  cups,  amount  to  the  same  thing. 

3284.  This  fact  however  shows  us,  that  it  may  be  proper 
where  the  circumstance  just  named  obtains,  namely,  congestion, 
that  it  may  be  proper  to  permit  a  sufficient  quantity  of  blood  to 
discharge  itself,  before  an  attempt  is  made  to  arrest  it — we  say 
a  sufficient  quantity  ;  by  this  we  mean,  a  quantity  that  will  re- 
lieve the  intensity  of  immediate  suffering,  or  that  removes  it  alto- 
gether; for  however  we  may  agree  in  the  propriety  of  preventing 
a  return  of  the  bleeding  by  the  means  already  suggested,  (par. 
3271  to  3276,)  we  are  nevertheless  impressed  with  the  necessity 
of  alleviating  the  immediate  symptoms.    Therefore,  in  plethoric 
and  robust  constitutions,  and  particularly  in  such  as  have  habitual 
determinations  to  the  head,  too  much  anxiety  should  not  be 
shown  on  account  of  the  continuance  of  the  bleeding,  unless  it 
persevere  beyond  the  absolute  necessity. 

3285.  But  if  this  happen,  or  the  returns  are  more  frequent 


BPISTAXIS.  715 

than  the  apparent  exigency  demands;  or  if  the  patient  become 
pale,  feeble,  and  emaciated,  the  haemorrhage  should  not  only  be 
stopped,  but  every  endeavour  should  be  exercised,  to  prevent 
subsequent  returns;  to  moderate  their  force;  or  to  abridge  their 
frequency. 

3286.  If  the  first  of  these  conditions  obtain,  namely,  a  greater 
expenditure  of  blood  than  the  immediate  necessity  demands,  and 
this  even  in  a  full  habit,  the  bleeding  should  be  stopped  as  soon 
as  possible  after  this  quantity  has  flowed ;  or  if  the  returns  are 
too  frequent,  or  if  the  patient  become  weak,  it  should  be  arrest- 
ed without  loss  of  time. 

3287.  For  these  purposes,  the  patient  should,  1st,  be  placed 
in  as  cool  a  situation  as  can  be  commanded  in  hot  weather,  or  as 
the  season  of  the  year  may  demand ;  2d,  he  should  be  kept  in  an 
erect  position;*  3d,  cold  applications  should  be  made  to  the  back 
of  the  neck,t  by  ice  and  water,  or  very  cold  water,  confined  in  a 
bladder,  to  prevent  unnecessary  wetting;  4th,  by  plugging  the 
nostril  or  nostrils,:}:  if  the  other  plan  does  not  succeed;  5th,  by 
blood-letting,  if  arterial  excitement  keep  up  after  the  removal  of 
head-ache,  or  other  inconvenience;  6th,  in  case  all  these  fail,  the 
acetate  of  lead,  in  doses  of  two  or  three  grains  with  a  quarter  of 
a  grain  of  opium,  every  two  or  three  hours  should  be  tried.   The 
spirit  of  turpentine  has  also  been  found  useful  in  twenty-drop 
doses,  every  hour  or  two,  in  a  little  sweetened  water;  and  the 
following  "styptic"  is  recommended  by  Dr.  Thatcher: — 


R.   Sulph.  cupri  -  -  gr.  iij. 

Acid,  sulph.  -  -  gut.  xx. 

Aq.  font.  -  '  -  §ij. 
f.  sol. 


Take  Blue  vitriol  -        3  grains. 

Oil  of  vitriol  -  20  drops. 

Water        -  -        2  ounces. 
Dissolve. 


Of  this  from  twenty  to  forty  drops  are  to  be  taken  in  a  little  wa- 
ter, every  hour  during  the  continuance  of  the  bleeding. 

*  We  would  advise  strict  attention  to  be  paid  to  this  direction,  as  its  influ- 
ence upon  the  bleeding  is  very  decided. 

f  It  has  been  common  to  recommend  cold  applications  to  the  scrotum  of 
males;  the  principle  on  which  this  is  directed,  we  do  not  understand,  if  it  be 
other  than  the  great  sensibility  of  this  part,  and  its  susceptibility  to  impression 
from  cold.  We  cannot  suppose,  or  rather  we  do  not  know  of  any  well-esta- 
blished fact  to  prove  a  peculiar  sympathy  between  the  scrotum  and  the  inter- 
nal lining  of  the  nose — we  are  therefore  of  opinion,  that  all  influence  derived 
from  such  applications  to  this  spot,  must  be  owing  altogether  to  the  strong  im- 
pression their  coldness  make  upon  it. 

t  A  piece  of  fine  old  linen  rag,  rolled  tight  into  a  cylindrical  form,  and  of  a 
size  sufficient  to  occupy  the  nostril,  should  be  gradually  twisted  up  it,  until  it 
reach  the  bleeding  vessel.  The  portion  of  the  plug  without  the  nostril  should 
be  cut  pretty  close  to  the  nose,  to  prevent  any  mechanical  disturbance  of  it — 
it  should  be  suffered  to  remain,  at  least  six-and-thirty  hours  before  it  be  re- 
moved. Some  have  recommended,  that  the  plug  should  be  wetted  with  some 
astringent  or  styptic  substance,  before  it  is  introduced;  but  we  believe  the  dry 
rag  answers  much  the  best. 


716  HAEMOPTYSIS. 

3288.  Where  the  bleeding  has  been  frequently  repeated,  and 
is  very  pertinacious,  the  blood  becomes  thin  and  watery ;  here 
the  quinine,  and  the  sulphuric  acid  are  necessary,  it  is  said.  Of 
the  utility  of  this  plan  we  can  say  very  little;  as  in  the  two  or 
three  cases  in  which  we  have  given  them  a  trial,  they  failed.  We 
have  found  the  extract  of  rhatany,  blisters,  together  with  purging 
with  aloetic  preparations,  to  answer  much  better.  Of  the  first, 
about  twenty  or  thirty  grains  a  day  should  be  given  in  pills  of 
three  or  four  grains  each.  The  blisters  should  be  applied  to  the 
neck ;  and  alternated  with  the  arms,  just  below  the  top  of  the 
shoulders;  and  the  pills  recommended,  (par.  293,)  will  answer 
a  valuable  purpose  as  cathartics.  Care  should  be  taken  to  keep 
the  feet  and  legs  warm ;  to  use  well-directed  exercise ;  to  sleep 
with  the  head  high,  and  without  covering;  and  to  have  nothing 
tight  round  the  neck.  Of  the  treatment  in  the  intervals  we  have 
already  spoken,  (par.  3264  to  3277.) 

SECT.  II. — HAEMOPTYSIS,  OR  BLEEDING  FROM  THE  LUNGS. 

32S9.  There  is  no  circumstance  connected  with  disease  that 
produces  so  many  melancholy  forebodings  as  "spitting  of  blood;" 
all  that  is  desponding  is  instantly  associated  with  its  appearance; 
and  all  that  is  hopeless  is  connected  with  its  perseverance.  That 
there  is  too  much  ground  for  apprehension  in  many  instances, 
we  freely  admit;  while  in  many  others,  there  is  nothing  to 
alarm. 

3290.  The  cultivation  of  morbid  anatomy  has  thrown  much 
light  upon  these  several  cases ;  and  well-conducted  pathological 
research  has  distinctly  pointed  out  the  cause  of  its  danger  on  the 
one  hand,  and  the  exemption  from  it  on  the  other.  Even  to  the 
time  of  Dr.  Cullen,  and  indeed  until  very  lately,  phthisis  pulmo- 
nalis  was  supposed  to  be  the  offspring  of  haemoptysis;  and  it  was 
not  known  till  after  Bayle,  Laennec,  Andral,  Louis,  &c.  had 
given  their  attention  to  the  investigations  of  this  subject,  that 
this  affection  was  found  to  be  the  consequence,  rather  than  the 
cause  of  tubercles,  or  of  consumption. 

3291.  Therefore,  however  alarming  or  even  suspicious  the 
discharge  of  blood  from  the  lungs  may  be,  it  is  never  to  be  con- 
sidered a«  the  cause  of  phthisis;  for  it  may  be  either  the  sign  of 
tubercles,  or  it  may  be  as  little  threatening,  asepistaxis,  or  bleed- 
ing from  the  nose;  for  like  this,  it  may  proceed  from  congestion 
or  local  determination,  which  becomes,  for  the  time  at  least,  re- 
lieved by  the  effusion  of  a  smaller  or  a  larger  quantity  of  blood. 

3292.  Haemoptysis,  by  its  mere  derivation,  would  import  any 
affection  in  which  blood  was  delivered  from  the  mouth ;  but  in 


HEMOPTYSIS.  717 

its  restricted  sense,  it  comprehends  only  such  discharges  as  pro- 
ceed from  the  trachea  or  bronchial  vessels. 

3293.  Next  to  epistaxis,  haemoptysis  is  the  most  common  of 
the  hasmorrhagies  ;  this  proceeds  most  probably  from  the  simi- 
larity of  conformation  of  the  parts  that  yield  the  blood  in  both 
instances — that  is,  from  their  great  vascularity  and  from  the  want 
of  a  protecting  pressure  upon  every  part  of  the  vessels  entering 
into  the  composition  of  the  respective  portions  of  the  mucous 
membrane  of  the  nose,  the  trachea  and  the  bronchia ;  (par.  3279,) 
and  also,  perhaps,  as  suggested  by  Dr.  Cullen,  the  proximity  of 

the  lungs  to  the  heart. 

f 

Causes. 

3294.  Haemoptysis  may  take  place  from  external  violence,  me- 
chanical irritation,  or  from  internal  causes,  either  of  determination 
or  peculiarity  of  conformation.     Thus,  we  have  known  spitting 
of  blood  to  follow  immediately  after  blows,  or  falls,  or  other 
violence ;  we  have  known  it  produced  by  irritating  substances 
being  drawn  into  the  lungs — once  from  a  portion  of  the  down 
from  the  "  cat-tail"  being  drawn  into  the  lungs — this  produced 
the  most  violent  haemorrhage  from  the  lungs  we  ever  remember 
to  have  witnessed  ;  and  once  we  saw  it  follow  the  breathing  of 
the  nitrous  oxyd  gas.  The  internal  causes  may  be  an  hereditary 
transmission  of  disposition  to  phthisis;  and  Dr.  Cullen  thinks  this 
always  implies  "  a  peculiar  and  faulty  conformation."     We  do 
not  however  altogether  believe,  that  hereditary  predisposition 
consists  in  a  faulty  conformation,  though  it  may  in  a  peculiar 
conformation,  as  this  may  be  made  to  mean  any  thing. 

3295.  But  we  think  it  may  be  said  with  truth,  that  when 
haemoptysis  arises  from  hereditary  predisposition,  it  nevej*  takes 
place  until  after  the  development  of  tubercles  within  the  lungs. 
And  it  may  be  further  observed,  that  in  such  cases,  this  affection 
may  be  anticipated  from  some  physical  imperfection  of  the  chest, 
such  as  its  narrowness,  and  the  elevation  of  the  shoulders.    The 
liability  to  this  disease  is  increased,  if  this  conformation  belongs 
to  one  of  a  sanguine  temperament,  and  consequently  in  one 
where  the  arterial  plethora  prevails.   In  a  word,  we  may  declare 
that  all  who  may  have  the  physical  marks  of  phthisis,  are  more 
or  less  obnoxious  to  haemoptysis. 

3296.  It  usually  commences  at  that  period  of  life  at  which  the 
body  is  about  to  receive  its  full  development ;  though  it  may, 
and  frequently  does  occur  later,  even  until  the  fortieth  year; 
after  this  period,  it  is  more  rare.     And  such  as  may  have  been 
subject  to  epistaxis  in  the  earlier  part  of  life,  are  also  very  liable 


718  HJEMOPTYSIS. 

to  this  species  of  haemorrhagy ;  or  females  who  may  have  suffer- 
ed a  suppression  of  the  catamenia;  as  also  males  who  may  have 
had  an  exemption,  from  some  sudden  cause,  from  the  bleeding 
piles. 

3297.  When  haemoptysis  proceeds  from  tubercles,  its  fre- 
quency and  quantity  will  very  much  depend  upon  the  number, 
the  rapidity,  or  slowness  of  their  development — hence,  we  see 
this  discharge  returning  at  intervals,   for  years,  without  any 
evident  increase   of  quantity,   or   any  manifest   augmentation 
of  danger;  at  other  times,  this  symptom  is  only  the  forerunner 
of  death. 

3298.  When  it  has  not  a  phthisical  origin,  it  may  occur  fre- 
quently, for  years,  without  manifest  injury,  and  the  subject  may 
even  die  at  an  advanced  age — of  this  we  have  known  several  re- 
markable instances.   This  observation  is  confirmed  by  several  of 
the  late  French  pathologists.     But  on  the  other  hand  many  die 
of  tubercular  consumption,  who  never  had  had  haemoptysis. 

3299.  Certain  professions  are  supposed  to  create  a  liability  to 
haemoptysis;  in  some  of  these  instances  we  believe  the  exciting 
cause  has  been  mistaken  for  the  predisposing — such  as  public 
speakers,  for  instance.    How  few  of  these  cause  haemoptysis  by 
their  exertions,  compared  with  those  who  may  provoke  it,  after 
predisposition  is  formed.     So  also  with  those  who  play  upon 
wind  instruments — of  this  class,  (and  we  have  been  many  years 
very  familiar  with  it,)  we  have  never  known  a  single  instance  of 
haemoptysis  being  produced  exclusively  by  professional  exer- 
tions.    Such  men  doubtless,  as  well  as  any  other  men,  be  their 
avocations  what  they  may,  will  occasionally  die  of  consumption; 
buipost  hoc,  ergo  propter  hoc,  is  not  always  sound  logic.     In- 
deed, we  are  of  opinion,  that  the  lungs  may  be  strengthened  by 
a  well-directed  exercise  of  them,  as  certainly  and  as  advanta- 
geously as  any  other  portion  of  the  system — nay,  even  predis- 
position we  believe  may  be  subdued  by  it. 

3300.  The  late  Dr.  Rush,  in  his  lectures,  used  to  inform  us, 
that  both  in  Germany  and  in  Holland,  consumption  was  compa- 
ratively a  rare  disease;  and  he  attributed  this  exemption  to  the 
early  and  free  use  made  of  the  lungs  in  these  countries,  as  all 
the  children  were  taught  to  sing  while  very  young.    And  in  his 
little  tract  on  "the  efficacy  of  common  salt  in  the  cure  of  haemop- 
tysis,"* he  says,  "  those  persons  who  have  been  early  instructed 
in  vocal  music,  and  who  use  their  vocal  organs  moderately  through 
life,  are  seldom  affected  by  an  haemorrhage  from  the  lungs.   Law- 
yers, players,  public  criers,  and  city  watchmen,  all  of  whom  ex- 
ercise their  lungs  either  by  long  or  loud  speaking,  are  less  affected 

•  Works,  Vol.  I.  p.  192. 


HEMOPTYSIS.  719 

by  this  disease  than  persons  of  other  occupations. "  Now  all  this 
is  in  strict  unison  with  our  own  observations. 

Phenomena. 

3301.  This  disease  attacks  variously,  sometimes  without  the 
slightest  premonition;  when  this  happens,  we  have  generally  ob- 
•served  the  most  extensive  discharges  to  follow.    This  happened 
in  our  own  ease.     In  1783,  we  suffered  the  most  profuse  and 
alarming  haemorrhage  from  the  lungs  we  almost  ever  witnessed; 
we  had  not  the  slightest  warning,  by  either,  a  preceding  cough, 
or  other  inconvenience;  and  we  were  for  several  years  liable  to 
returns  of  it,  without  our  ever  being  able  to  foretel  it  was  about 

•  to  take  place.  But  in  general,  this  disease  is  ushered  in  by  a 
slight  cough,  and  the  bringing  up  of  a  little  mueus,  tinged  with 
blood ;  or  it  may  even  for  the  first  time  be  pure  blood ;  and  this 
in  varying  quantity.  At  other  times  there  may  be  both  local 
and  general  symptoms,  which  announces  this  discharge  to  be 
about  to  take  place;  such  as  uneasiness,  lightness,  or  pain  in  some 
one  portion  of  the  chest;  for  there  is  no  fixed  spot  for  either 
pain,  heat,  stricture,  or  other  uneasy  sensations.  There  may  be, 
however,  some  little  want  of  freedom  in  breathing,  with  an  oc- 
casional urgent  desire  to  expand  the  lungs. 

3302.  A  dry  cough,  or  a  very  scanty  expectoration  of  frothy 
mucus ;  a  disagreeable  sweetish  or  saltish  taste  in  the  mouth ; 
lassitude,  flushed  face,  or  pale  cheeks;  head-ache,  chilliness, 
fever;  pulse  quick,  hard,  and  sometimes  very  frequent.     A  rat- 
tling may  sometimes  be  heard  in  the  thorax,  especially  if  the 
quantity  of  blood  effused  be  small ;  for  it  will  then  become  mix- 
ed with  air  and  give  the  sound  just  named. 

3303.  When  the  blood  is  thus  confined  within  the  bronchia, 
it  very  often  excites  coughing,  and  more  or  less  is  brought  up 
into  the  fauces,  and  from  thence  discharged  by  spitting.     This 
blood  is  almost  always  of  a  bright  arterial  colour,  and  its  quan- 
tity may  vary  from  a  few  streaks  up  to  several  pounds.     This 
may  happen  in  a  few  minutes,  or  it  may  occupy  several  hours, 
nay  days.     The  blood  will  sometimes  be  very  dark,  and  come 
up  with  more  or  less  difficulty,  in  small  coagula,  especially  when 
the  haemorrhagic  effort  is  about  to  cease. 

3304.  The  periods  of  return  of  this  haemorrhagy  is  very  va- 
riable; the  intervals  generally  are  longer  in  such  cases  as  are  not 
complicated  by  tubercles;  but  this  may  be  much  influenced  by 
the  habits  of  the  patient,  or  the  less  or  greater  frequency  of  the 
application  of  the  remote  causes.   The  liability  to  returns  of  this 
complaint  will  therefore  be  very  much  influenced  by  the  nature 
and  operation  of  these  causes. 


720  HAEMOPTYSIS. 

3305.  As  it  is  impossible  in  many  instances  of  haemoptysis  to 
determine  its  remote  cause,  it  would  be  always  best  to  explore 
the  chest  by  the  stethoscope;  this  would  render  our  therapeutical 
views  more  distinct  and  certain,  especially  as  tubercles  may  be 
looked  upon  as  the  most  frequent  cause  of  this  complaint.     And 
on  the  other  hand,  we  may  have  it  in  our  power  by  this  means, 
to  relieve  in  some  instances,  a  depressing  apprehension,  where 
this  discharge  lakes  place  from  other  causes  than  tubercles,  and 
at  the  same  time  remove  a  dread  of  its  eventual  bad  tendency, 
as  we  have  no  evidence  that  the  spitting  of  blood  ever  produces 
tubercles.     " It  is  worthy  of  remark,"  says  Laennec,   "that  a 
haemoptysis  produced  by  violence,  as  a  blow  upon  the  chest,  vio- 
lent running,  a  fit  of  passion,  immoderate  exercise  of  the  voice, 
&c.  is  most  commonly  productive  of  no  further  consequences* 
when  it  is  once  got  under;  whilst  phthisis  frequently  supervenes 
immediately  to  a  haemorrhage  arising  without  any  obvious  cause, 
but  which  no  doubt  has  for  its  real  cause,  tubercles  which  had 
previously,  and  perhaps  for  a  long  time  been  latent  in  the  lungs." 
p.  327.     Louis  strongly  supports  Laennec  in  this  opinion,  (see 
note  to  par.  1755.)     Andral  says,  "of  persons  who  have  had 
haemoptysis,  one-fifth  part  have  no  tubercles  in  the  lungs;  and 
of  those  who  die  of  phthisis,  one-sixth  do  not  spit  blood  at  any 
period  of  the  disease."* 

3306.  It  is  therefore  a  matter  of  great  consolation,  that  other 
causes  than  tubercles  may  produce  haemoptysis,  and  that  when 
it  does  arise  from  other  causes  but  little  danger  attends  it  in  com- 
mon.    Thus,  whatever  is  capable  of  irritating  the  mucous  mem- 
brane of  the  bronchia,  to  a  certain  extent  may  occasion  a  dis- 
charge of  blood  from  the  lungs.     Hence,  we  find  it  sometimes 
attending  bronchitis  or  severe  catarrh ;  to  follow  from  sudden 
changes  of  temperature,  as  from  a  very  cold,  to  a  hot  atmos- 
phere, &c. 

Proximate  Cause. 

3307.  The  proximate  cause  of  haemoptysis  has  generally  been 
ascribed  to  a  rupture  of  one  or  more  blood-vessels,  and  this  by 
mechanical  violence — such  as  a  change  in  barometrical  pressure; 
sudden  and  severe  exertions,  as  lifting  heavy  weights,  carrying 
heavy  loads,  &c.  (par.  3262.)    In  these  instances,  it  is  supposed 
by  Cullen,  Good,  and  others,  that  an  increased  action  of  the  heart 
causes  an  unusual  determination  of  blood  to  the  lungs,and  thusrup- 
ture  the  vesselsby  over-stretching  them.  But  this  opinion, however 
naturally  it  may  suggest  itself,  from  violence  having  immediately 

•  Clin.  Med.  t.  iii.  p.  181. 


HJSMOPTFSIS.  721 

preceded  the  discharge  of  blood,  does  not  appear  to  be  well-found- 
ed; upon  this  we  have  already  had  occasion  to  remark,  (par.  3261,) 
and  what  we  have  there  said,  will  give  the  opinion  of  Chomel, 
and  we  believe  of  nearly  all  the  present  French  pathologists;  we 
therefore  without  hesitation  adopt  this  explanation. 

3308.  It  has  been  said  by  some,  that  the  explanation  of  the 
manner  in  which  the  blood  issues  from  the  vessels,  is  not  satis- 
factory ;  as  the  quantity  discharged  is  very  much  too  great  to 
proceed  from  the  vessels  in  the  manner  described.     To  this  ob- 
jection, Dr.  Condie  says,  "let  any  one  cite  to  us  a  case  of  the 
most  excessive  haemorrhage,  and  we  can  present  to  him  one  of 
simple  expectoration  or  flux  of  mucus,  in  which  the  amount  of 
fluid  discharged  shall  exceed  the  quantity  of  blood  poured  out  in 
the  former."    "It  is  now  satisfactorily  ascertained  that  the  ves- 
sels of  a  part,  when  labouring  under  irritation,  have  the  power 
of  exhaling  blood,  in  the  same  manner  they  do  serum,  or  other 
fluids,  and  probably  to  as  great  an  extent."* 

3309.  It  may  perhaps  be  objected,  that  Dr.  C.  has  taken  the 
product  of  the  whole  pulmonary  surface  to  compare  with  the 
yield  of  a  single  blood-vessel,  in  the  same  given  time,  which 
would  not  be  fair;  for  if  a  comparison  be  instituted,  regard  should 
be  had  to  the  extent  of  surface  occupied  in  giving  out  blood,  as 
well  as  that  which  pours  out  serum  or  mucus;  the  latter  of  which 
would  be  found  perhaps  infinitely  less  than  that  of  the  former, 
and  of  course,  the  torrent  which  sometimes  pours  from  the  mouth 
in  haemoptysis,  can  therefore  only  be  accounted  for,  on  the  sup- 
position that  a  vessel  has  been  ruptured ;  and  if  we  add  to  this 
the  suddenness  with  which  the  bleeding  takes  place,  the  opinion 
seems  to  be  strengthened. 

3310.  This  would  appear  to  be  a  reasonable  objection  at  first 
sight,  but  if  narrowly  examined,  it  will  be  found  to  be  more 
specious  than  solid.     First,  because  the  ruptured  vessel  or  ves- 
sels have  never  been  detected  ;  second,  because  it  is  ascertained 
that  the  blood-vessels  when  under  certain  irritations,  will  exhale 
blood  instead  of  serum  or  mucus,  (par.  3261;)  third,  because  we 
have  seen  the  whole  surface  of  the  mouth  and  fauces  yield  blood 
as  fast  as  it  could  be  removed;  and  this  to  a  large  amount  in  the 
twenty-four  hours,  without,  the  slightest   discoverable  lesion. 
And  Mr.  Paisley  relates  a  case  of  death  from  protracted  labour, 
where  the  death  of  the  patient  could  not  be  accounted  for,  as 
there  was  no  apparent  hasmorrhagy;  leave  was  obtained  to  open 
the  body,  and  upon  exposing  the  uterus,  it  was  found  covered 
with  a  coagulum  of  blood,  which  upon  measurement  was  found 
to  be  "a  foot  and  a  quarter  long,  a  'foot  broad,  and  a  quarter  of 

*  North  Am.  Med.  and  Surg.  Journ.  Vol.  V.  p.  29. 
91 


722  HAEMOPTYSIS. 

an  inch  thick."  There  was  no  blood  in  Ihe  cavity  of  the  abdo- 
men, nor  could  the  slightest  lesion  of  the  surface  of  the  uterus 
be  detected.*  Fourth,  because  congestive  irritation  can  cause 
very  rapid  determinations  to  either  the  lungs,  brain,  liver,  spleen, 
&c.  and  this  to  a  very  great  extent.  We  knew  in  the  course  of 
a  few  minutes,  a  very  extensive  engorgement  of  the  spleen  to 
take  place  in  a  lady;  her  left  side  became  swollen  and  very  sud- 
denly tender;  upon  examination,  the  spleen  was  found  to  be 
excessively  enlarged;  so  much  so,  as  to  appear  to  rest  in  the 
fossa  of  the  ilium.  The  patient  quickly  became  pale  and  faint; 
respiration  was  hurried,  and  the  pulse  very  small  and  frequent; 
these  latter  symptoms  were  .accounted  for,  by  referring  to  the 
large  abstraction  of  blood  from  the  general  system,  by  this  one 
viscus.  In  the  lungs,  hepatization  or  haemorrhage  may  take 
place-,  when  they  become  the  seat  of  congestive  irritation,  and 
the  extent  of  this  will  be  determined  by  the  degree  of  irritation; 
it  may  therefore  be  very  partial, -or  it  may  be  very  extensive. 
Fifth,  the  modus  operandi  of  certain  remedies  cannot  be  explain- 
ed upon  the  presumption  that  a  rupture  of  vessels  is  essential  in 
all  cases  of  haemoptysis;  such  as  swallowing  common  salt,  taking 
the  acetate  of  lead,  &c. 

3311.  Notwithstanding  our  objections  to  the  proximate  cause 
of  hemoptysis,  as  commonly  delivered,  we  would  not  deny  ab- 
solutely the  occasional  rupture  of  a  vessel;  especially  as  Laennec 
admits  two  possible  cases  of  this  kind ;  the  first,  is  where  an 
aneurism  bursts  into  the  bronchia  or  trachea;  the  second,  wren 
a  tuberculous  excavation  has  a  vessel  to  rupture  within  it.  These 
cases  however,  he  observes,  are  almost  immediately  followed  by 
death,  and  consequently  cannot  explain  the  phenomena  of  haemop- 
tysis, as  this  occurs  so  frequently. 

Treatment. 

3312.  The  treatment  of  haemoptysis  will  necessarily  divide 
itself  into  what  is  necessary  to  be  done  during  the  discharge  of 
blood  ;  and  into  what  may  be  proper  to  prevent  a  return  of  it. 

Treatment  during  the  Flow  of  Blood. 

3313.  The  directions  already  given  for  the  treatment  of  epis- 
taxis,  will  apply  here  to  a  certain  extent.     As  a  general  rule  in 
the  treatment  of  haemorrhagies,  position  is  always  to  be  consider- 
ed of.  consequence — that  is,  the  patient  should  be  placed  in  such 
a  manner,  as  to  lessen  the  determination  of  the  blood  to  the 
bleeding  part,  by  opposing  to  it,  gravitation.    In  bleedings  from 

*  Edin.  Med.  Ess.  Vol.  IV.  p.  355. 


HEMOPTYSIS.  723 

the  lungs  therefore,  the  patient  should  be  kept  sitting  erect,  both 
day  and  night,  if  the  discharge  be  considerable  or  obstinate — 
for  this  purpose  a  large  "easy  chair"  is  a  proper  thing;  as  the 
body  may  rest  in  it  without  changing  from  an  upright  position. 
The  legs  and  feet  can  be  occasionally  supported  by  chairs,  on 
which  pillows  are  placed  ;  and  when  tired  of  this  position,  they 
can  be  put  down. 

3314.  The  air  of  the  chamber  should  be  cool,  and  frequently 
changed  by  ventilation.     The  patient  should  be  forbidden    to 
speak;  a  slate,  or  paper  and  pencil  may  be  furnished  to  him,  to 
prevent  this  exertion.     Every  thing  tending  to  increase  the  mo- 
tion of  the  blood  should  be  strictly  avoided;  therefore,  both  mo- 
ral and  physical  agitation  must  be  carefully  guarded  against.   All 
embarrassments  to  respiration  should  be  removed ;  even  the  weight 
of  the  covering  should  be  diminished  and  no  more  suffered  to  re- 
main than  will  barely  secure  a  very  moderate  degree  of  warmth. 
All  unnecessary  attendants  should  be  dismissed  the  room;  and 
the  most  perfect  quiet  must  be  observed. 

3315.  If  the  discharge  be  recent,  the  patient  should  be  made 
to  swallow  a  tea-spoonful  of  fine  salt,  as  directed  by  Dr.  .Rush, 
drinking  after  it  a  large  glass  of  cold  water;  if  the  pulse  be  ac- 
tive, blood  should  be  taken  from  the  arm,  observing  to  abstract 
it  as  suddenly  as  possible,  be  the  necessary  quantity  much  or 
little,  in  order  to  make  as  much  impression  on  the  arterial  system 
as  possible. 

3316.  Whatever  may  have  been  the  remote  cause  of  haemop- 
tysis, if  it  be  frequently  repeated,  though  it  be  in  a  moderate 
degree,  it  is  very  common  for  it  to  observe  a  periodical  move- 
ment— and  this  is  remarkably  the  case,  when  it  proceeds  from 
tubercles,  and  these  suppurating.     When  this  is  about  to  take 
place,  it  is  frequently  preceded  by  sensations  that  declare  it  to 
be  at  hand  ;  such  as  flushing  of  the  face ;  hot  hands ;  cold  feet;  a 
sense  of  tightness  or  fulness  in  the  chest;  an  increase  of  cough, 
with  expectoration  tinged  with  blood.     If  this  warning  take 
place,  it  behooves  the  patient  not  to  neglect  the  friendly  admo- 
nition, lest  he  suffer  by  his  neglect — he  should  immediately  lose 
a  little  blood,  have  his  bowels  opened  by  either  of  the  neutral 
salts,  moderate  his  diet,  or  even  take  nothing  but  barley  water; 
observe  the  most  perfect  quiet,  and  should  the  cough  require  ap- 
peasing, to  take  a  moderate  dose  of  Dover's  powder,  (ten  grains,) 
at  bed-time.     The  patient  had  better  sleep  in  a  sitting  posture, 
(par.  3313,)  in  a  cool  room  ;  and  if  his  feet  be  cold,  to  have  them 
placed  in  the  mustard  bath,*  and  suffered  to  remain  in  it  until 
they  glow. 

*  That  is,  warm  water  with  a  quantity  of  the  flour  of  mustard  mixed  in  it. 
(See  note  to  par.  3277.) 


724  HAEMOPTYSIS. 

3317.  The  same   directions  will  serve  for  the  treatment  of 
haemoptysis,  that  is  frequent  or  more  seldom  in  its  returns.     For 
after  the  haemorrhage  has  taken  place  in  any  quantity,  the  object 
is  to  arrest  it;  and  the  nature  of  the  remedies  will  necessarily 
depend  upon  the  state  of  the  system,  as  has  already  been  suggest- 
ed.   But  these  precautionary  measures  should  be  confined  to  the 
instances  in  which    the    patients    experience  the    premonitory 
symptoms  named  above ;  for  when  bleeding  is  resorted  to,  and 
the  other  measures  put  in  practice,  where  there  is  no  evidence 
of  plethora  or  of  haemorrhagic  effort,  it  is  sure  to  do  mischief  by 
perpetuating  weakness,  and  preventing  the  full  exercise  of  the 
recuperative  powers  of  the  system.    At  least  this  was  markedly 
the  case  in  the  haemoptysis  which  pursued  us  for  several  years, 
with  more  or  less  violence.     For  it  was  not  until  we  used  exer- 
cise freely,  but  carefully ;  and  resumed  the  use  of  animal  food ; 
together  with  learning  to  play  the  flute,  that  this  haemorrhage 
ceased. 

3318.  It  would  therefore  always  be  desirable  to  discriminate 
between  the  haemoptysis  that  may  be  accidentally  produced,  and 
the  one  which  may  arise  from  tubercles — for  this  purpose  the  ste- 
thoscope should  always  be  employed. 

3319.  Cases  not  unfrequently  occur,  in  which  it  is  every  way 
desirable  to  diminish  the  capillary  congestion,  without  drawing 
blood  from  the  general  system,  especially  in  such  cases  as  obey 
a  periodical  movement,  accompanied  by  premonitory  symptoms ; 
or  in  such  cases  as  may  have  the  haemorrhage  provoked  by  a 
slight  increase  of  arterial  action.     For  this  purpose,  "dry  cup- 
ping" between  the  shoulders  answers  extremely  well ;  but  if 
fever  attend,  with  evening  exacerbations,  the  "  wet  cupping" 
may  be  resorted  to — these  operations  should  be  conducted  as  re- 
commended in  Chapter  on  Rheumatism. 

Cathartics. 

3320.  Of  these  we  have  already  spoken,  (par.  3274,  page  712.) 
In  addition  to  what  we  have  said  there,  we  shall  merely  suggest, 
that  much  advantage  is  derived  from  the  use  of  the  aloetic  purga- 
tives, in  men  who  may  have  been  liable  to  haemorrhoids,  and  to 
females  about  the  cessation  of  the  menses. 

Diuretics. 

3321.  Diuretics  have  been  recommended  in  the  treatment  of 
haemoptysis ;  of  their  operation  we  can  say  nothing  from  our  own 
experience,  unless  nitre  and  digitalis  be  considered  as  such  in 
this  case,  neither  of  which  have  we  tried  to  any  extent. 


HAEMOPTYSIS.  725 


Emetics. 

3322.  We  believe  that  Dr.  Bryan  Robinson  was  the  first  to 
recommend  emetics  in  active  haemorrhage.  We  have  never  tried 
them  ourselves  in  haemoptysis — Dr.  Chapman  speaks  highly  of 
them.*  We  once  saw  the  most  astonishing  effect  from  an  emetic, 
in  a  case  of  bleeding  from  the  gums,  (par.  3310,)  attended  by 
Dr.  Chapman  and  myself.     This  haemorrhage  occurred  during 
convalescence  from  a  severe  remittent  fever,  which  had  been 
converted  into  an  intermittent.     The  patient  supposed  he  lost  a 
quart  or  more  during  the  night;  and  he  certainly  lost  an  equal 
quantity  in  the  next  twenty-four  hours,  though  all  the  usual  re- 
medies were  tried  in  turn.     Dr.  C.  proposed  an  emetic;  it  was 
given ;  and  it  really  acted  like  a  charm — the  bleeding  stopped 
instantly.   About  four  days  after  it  had  stopped,  it  returned,  but 
not  with  as  much  force ;  another  emetic  was  given,  and  the  same 
sudden  and  more  effectual  result  followed.  Dr.  Chapman  recom- 
mends the  ipecacuanha  as  the  preferable  emetic. 

Blisters. 

3323.  Blisters  applied  to  the  chest,  or  where  we  think  better, 
between  the  shoulders,  should  never  be  omitted  in  the  treatment 
of  haemoptysis,  after  the  more  active  stage  of  the  disease  has 
•passed. 

Partial  Warm  Bath. 

3324.  The  French  practitioners  recommend  the  partial  appli- 
cation of  hot  water,  to  which  the  flour  of  mustard  or  common 
salt  has  been  added.  The  hands  and  feet  are  directed  to  be  placed 
in  it,  with  a  view  of  producing  a  revulsion  from  the  lungs — but 
this  is  never  to  be  used  unless  the  bleeding  continue  after  the 
period  in  which  the  lancet  or  other  antiphlogistic  means  are 
thought  to  be  necessary. 

Cough. 

3325.  Haemoptysis  is  almost   constantly    accompanied   by 
cough — this  troublesome  symptom  should  be  quieted  as  quickly 
and  as  effectually  as  possible.  For  this  purpose,  the  employment 
of  opium  in  some  form  or  other  is  absolutely  necessary.  Almost 
every  practitioner  has  his  favourite  prescription ;  we  therefore 

•  Amer.  Journ.  of  Med.  Sciences,  Vol.  II.  p.  120. 


726  HJEMATEMESIS. 

shall  say  very  little  as  regards  the  various  forms  in  which  this 
drug  is  administered,  and  merely  indicate  what  we  have  gene- 
rally used  and  found  useful  in  quieting  this  distressing  attendant.  * 
When  the  complaint  is  of  long  standing,  and  has  hecome  chronic, 
we  have  found  the  following  combination  answer  an  admirable 
purpose. 

R.     Tinct.  Tolut. 


Thebaic.  - 


Digital. 

M. 


Take  Tincture  of  Tolu        1  ounce. 
Laudanum         -        2  drachms. 
Ti  ncture  of  Foxglove  1  drachm. 
Mix. 


Of  this  forty  or  fifty  drops  may  be  taken  every  three  or  four 
hours,  on  a  little  dry  brown  sugar,  or  mixed  in  a  little  sweeten- 
ed milk,  and  increase  as  occasion  may  require. 

3326.  When,  however,  the  hsemorrhage  is  more  recent,  we 
have  found  the  spermaceti  mixture  to  answer  admirable;  or 
should  this  be  offensive  to  the  stomach,  the  brown  mixture  will 
be  found  an  excellent  substitute.  See  par.  1310,  page  393.  We 
have  lately  used  the  following  mixture  with  great  advantage," 
where  opium  was  apt  to  disagree,  and  where  the  skin  was  dry 
and  husky. 


JJ.    Morphia       -         -         -  gr.  ij 

Vin.  ipecac.         -         -  sjiij. 

Sacch.  alb.          -        -  gij. 

Aq.  font.     ...  Jviij. 
M. 


Take  Morphia  2  grains. 

Ipecac,  wine  -         3  drachms. 

White  sugar  -        2  drachms. 
Water  8  ounces. 

Mix. 


Of  this  a  table-spoonful  may  be  taken  every  three  or  four  hours, 
or  as  occasion  may  require. 

Diet. 

3327.  Of  this,  we  have  already  spoken  in  the  general,  (par. 
3271.)    We  would,  however,  in  all  cases  of  haemoptysis,  except 
the  accidental,  confine  the  patient  to  a  very  moderate  quantity 
of  even  vegetable  substances,  during  the  more  active  stages  of 
the  disease.     The  vegetable  jellies,  as  rice,  tapioca,  sago,  arrow 
root,  rennet  whey,  buttermilk,  well-mashed  Irish  potatoes,  tur- 
nips, and  the  fruits  of  the  season,  should  form  the  basis  of  his 
diet.     Pure  water,  toast  water,  flaxseed,  or  slippery-elm  bark 
tea,  rice  water,  molasses  and  water,  with  either  a  little  lemon 
juice  or  vinegar,  or  lemonade,  should  constitute  his  drinks. 

SECT.  III. — H.EMATEMESIS,  OR  VOMITING  OF  BLOOD. 

3328.  This  form  of  haemorrhage  is  very  much  more  rare  than 
either  of  those  just  treated  of.     Pinel*  defines  haematemesis  to 

*  Diet,  des  Science  Med.  Art.  Haematemesis. 


H-EMATEMESIS.  727 

be  "a  vomiting  of  blood,  more  or  less  red,  sometimes  black, 
fluid,  or  coagulated,  almost  always  mixed  with  mucus  or  other 
substances  contained  in  the  stomach,  and  sometimes  accompanied 
with  dejections  of  blood,  of  various  colours.'7 

3329.  We  have  already  declared  that  we  are  far  from  having 
ascertained  the  precise  condition  of  the  parts  that  yield  the  blood 
in  spontaneous  haemorrhagy ;  nor  is  our  embarrassment  lessened 
in  studying  their  pathological  state,  when  a  discharge  of  blood 
takes  place  from  the  stomach ;  for  the  same  explanation  is  gene- 
rally given  in  this  case  as  is  offered  in  epistaxis  or  in  haemopty- 
sis— namely,  a  rupture  of  a  vessel.   We  have  attempted  to  show 
that  this  is  not  the  true  state  of  the  parts  concerned  in  the  two 
other  haemorrhagies,  and  its  probability  is  not  increased  when 
we  consider  the  phenomena  of  hsematemesis ;  the  presumption, 
however,  is,  that  the  exhalants  pour  out  the  blood  that  is  dis- 
charged in  this  species  of  haemorrhage,  after  the  manner  they 
do  in  bleeding  from  the  nose  and  in  spitting  of  blood.     For  we 
must  admit  as  every  way  probable,  that  the  congestive  irritation 
may  be  as  certainly  seated  in  the  stomach,  as  it  appears  known 
to  be  the  case  in  the  brain,  lungs,  or  other  of  the  viscera. 

3330.  One  thing  seems  to  be  very  certain,  that  it  does  not 
always  proceed  from  the  same  cause,  nor  is  it  always  followed 
by  the  same  consequences.     On  this  account  it  has  been  divided 
into  five  species  by  Pine!,*  as  follows: — 1.  The  constitutional 
haematemesis. — 2.  The  accidental  haematemesis. — 3.   The  succe- 
daneous,  or  vicarious  haematemesis. — 4.   The  splanchnic  haema- 
temesis.— 5.  The  critical  haematemesis. 

1.   The  Constitutional  Hasmatemesis. 

3331.  By  this  is  understood  a  discharge  of  blood  from  the 
stomach  arising  from  an  inherent  badness  of  constitution,  and 
not  dependent  upon  any  appreciable  or  cognizable  cause.     This 
species  may  have  its  origin  in  a  radical  weakness  of  organization, 
in  an  excess  of  organic  strength,  in  plethora,  or  in  too  much  en- 
ergy in  the  arterial  system.  Pinel  cites  from  several  authorities, 
examples  proving  the  agency  of  the  several  enumerated  causes, 
in  all  of  which  every  attempt  at  relief  was  abortive  or  followed 
by  bad  consequences — this  species,  therefore,  cannot  advanta- 
geously be  interfered  with. 

2.   The  Accidental  Hsematemesis, 

3332.  This  species  is  by  much  the  most  frequent  of  the  five 
just  enumerated ;  as  it  may  have  for  its  production  a  variety  of 

*  Loc.  Cit. 


728  HJBMATEMESIS. 

exciting  causes,  as  a  fit  of  anger,  the  sudden  suppression  of  the 
menses,  &c.  A  case  is  given  by  Pinel,  from  Gerard,  to  prove 
the  agency  of  these  causes.  A  washerwoman,  aged  thirty-five 
years,  fell  senseless  twice  from  a  fit  of  passion,  while  the  menses 
were  flowing;  they  were  suddenly  suppressed;  after  two  or  three 
days  of  pretty  severe  indisposition,  a  vomiting  of  blood  took 
place,  together  with  bloody  dejections.  The  other  instance  oc- 
curred in  a  young  woman  who  was  about  to  make  a  desirable 
connexion,  but  who  received  some  account  suddenly,  that  put 
an  end  to  her  wishes ;  she  was  menstruating ;  the  menses  were 
suspended;  a  vomiting  of  blood  followed,  which  continued  five 
or  six  days,  and  then  .ceased  without  any  serious  consequence 
following. 

3333.  Mechanical  causes  may  also  produce  vomiting  of  blood; 
as  may  acrid  or  irritating  substances  taken  within  the  stomach 
itself.     We  once  witnessed  this  affection  produced  by  a  severe 
kick  of  a  horse  upon  the  epigastric  region;  and  another  in  a  wo- 
man of  the  town  who  had  taken  both  arsenic  and  laudanum,  for 
the  purpose  of  destroying  herself,   which  was  very  speedily 
effected. 

3.   The  Succedaneous  Haematemesis. 

3334.  This  name  is  given  to  the  vomiting  of  blood  which  suc- 
ceeds the  suppression  of  a  sanguineous  discharge.     This  species 
observes  the  same  progress,  and  returns  at  the  same  periods.    It 
is  not  unfrequently  vicarious  to  menstruation,  but  more  rarely 
to  haemorrhoids.     Several  interesting  cases  are  recorded,  pur- 
porting to  establish  this  exchange  of  office;  but  our  limits  will 
not  permit  us  to  quote  them.     Our  own  experience  has  never 
furnished  us  with  an  example  of  this  kind. 

4.    The  Splanchnic  Hsematemesis. 

3335.  Under  this  title  is  comprehended  the  vomiting  of  blood, 
which  is  caused  by  an  organic  lesion  of  some  one  of  the  abdomi- 
nal viscera,  as  the  spleen,  the  liver,  the  pancreas.*    In  this  spe- 

•  Dr.  Chapman  and  the  author  have  lately  had  an  opportunity  to  witness  a 
most  interesting  case,  in  which  the  pancreas  was  entirely  scirrhous.  Mr.  L. 
aged  forty-six  years,  found  his  health  decline  during  the  last  eighteen  months. 
In  August,  1831,  he  complained  much  of  dyspeptic  symptoms,  and  for  which 
I  prescribed  a  suitable  regimen  and  some  laxative  medicine — he  thought  him- 
self much  improved  by  the  plan  laid  down,  until  about  the  latter  end  of  Feb- 
ruary, 1832.  About  this  time  he  was  attacked  by  a  vomiting  of  an  enormous 
quantity  of  a  black  matter,  resembling,  in  all  its  physical  properties,  that 
thrown  up  in  the  last  stage  of  yellow  fever.  This  throwing  up  took  place 
about  every  twenty-four  hours,  and  as  soon  as  it  was  discharged  his  feelings 


H2EMATEMESIS.  729 

cies  the  vomiting  is  symptomatic ;  it  is,  however,  declared  to  be 
both  frequent  and  dangerous,  though  not  a  primitive  affection, 
and  consequently  not  strictly  perhaps  entitled  to  a  place  here, 
yet  its  danger  entitles  it  to  a  consideration.  A  number  of  cases 
upon  record  show  most  satisfactorily,  that  lesions  of  any  of  the 
principal  abdominal  viscera  may  cause  a  vomiting  of  blood, 
either  directly  by  blood  being  thrown  into  the  stomach,  and 
then  evacuated  from  it  by  its  own  efforts,  or  indirectly  by  con- 
gestive irritation.  For  a  number  of  such  cases  we  refer  to  the 

work  above  cited. 

• 

5.    The  Critical  aasmatemesis. 

3336.  This  species  is  produced  when  nature  directs  her  efforts 
towards  the  stomach,  to  relieve  disease  elsewhere  situated ;  it  is 
not  often  observed  in  acute  diseases.   In  chronic  affections,  how- 
ever, we  have  a  number  of  cases  upon  record,  especially  by  the 
older  writers,  in  which  haematemesis  was  followed  by  a  return 
of  health,  where  every  circumstance  seemed  distinctly  to  de- 
clare, either  the  liver,  the  spleen,  or  the  pancreas,  was  the  seat 
of  the  original  affection.* 

Proximate  Cause. 

3337.  We  must  regard  haematemesis  as  an  haemorrhagy,  dif- 
fering in  nothing  from  epistaxis  or  haemoptysis  except  in  loca- 
tion. The  same  condition  of  the  exhalants  is  present  in  this  spe- 
cies as  in  the  haemorrhagies  just  mentioned;  that  is,  the  mucous 
membrane  has  its  exhalants  to  pour  out  blood  instead  of  mucus. 

3338.  Post  mortem  examinations  of  those  who  have  died  of 

were  very  much  more  comfortable.  His  bowels  yielded,  a  black,  tarry,  tena- 
cious substance,  when  they  were  moved,  which  was  however  seldom,  though 
urged  by  a  variety  of  cathartic  medicines.  He  suffered  no  very  acute  pain, 
though  there  was  tenderness  in  almost  every  part  of  the  abdomen  upon  pres- 
sure. He  made  urine  freely;  and  it  was  of  a  healthy  appearance.  His  thirst 
•was  very  great;  his  tongue  moist,  but  redder  than  natural.  His  pulse,  but  little 
quickened,  and  was  sufficiently  firm.  Singultus  supervened,  to  a  very  distress- 
ing degree.  His  mind  was  perfectly  composed,  and  resigned;  and  he  died 
without  much  suffering. 

Dr.  Horner  kindly  examined  the  body — the  pyloric  extremity  of  the  stomach 
was  found  to  be  scirrhous,  and  bearing  marks  that  it  would  soon  have  ulcerated. 
Its  calibre  was  much  contracted;  the  inner  coat  of  the  stomach  was  softened — 
its  veins  were  distended  with  a  black  fluid  every  way  resembling  that  thrown 
up  by  vomiting,  and  of  which  it  contained  a  considerable  quantity.  The  pan- 
creas was  scirrhous  in  every  portion  of  it.  The  colon  was  highly  inflamed,  in 
very  many  patches.  The  rest  of  the  abdominal  viscera  were  free  from  disease. 

The  black  matter  thrown  up  was  an  altered  venal  blood,  and  as  regards  quan- 
tity very  much  exceeded  the  liquids  swallowed. 

*  See  Diet,  des  Science  Med.  loc.  cit. 

92 


730  H.BMATEMESIS. 

haematemesis,  present  different  appearances;  if  the  disease  have 
been  very  acute  and  suddenly  fatal,  no  trace  of  disease  has  been 
observed.  At  other  times,  the  mucous  membrane  has  been  found 
black ;  its  vessels  dilated,  but  very  rarely  ruptured.  By  injecting 
the  trunks  of  the  gastric  arteries,  M.  Portal  made  the  injected 
matter  pass  into  the  stomach  itself — in  a  word,  the  mucous  mem- 
brane was  more  or  less  inflamed. 

3339.  In  those  who  died  of  the  splanchnic  species,  the  spleen 
has  been  found  hard,  even  cartilaginous,  or  very  soft,  and  its 
parenchyma  distended  with  black  blood.   The  liver  has  present- 
ed a  variety  of  appearances,  from  simple  engorgement,  to  con- 
firmed scirrhus.  The  pancreas  has  had,  in  some  rare  cases,  lesions 
of  a  greater  or  less  extent. 

Diagnosis. 

3340.  At  first  sight,  it  might  appear  almost  impossible  that  a 
vomiting  of  blood  should  not  instantly  be  distinguished  from 
hemoptysis,  as  an  effort  to  vomit  is  so  conspicuous  a  symptom. 
Yet  this  is  not  so  in  every  instance;  we  have  known  these  hae- 
morrhagies  twice  confounded,  though  much   pains  was  taken  to 
ascertain  the  point  in  the  commencement.   Sometimes  these  two 
diseases  complicate  each  other,  which  increases  the  embarrass- 
ment still  more.     Notwithstanding,  therefore,  that  the  action  of 
vomiting  is  a  remarkable  and  well-defined  effort,  it  is  occasion- 
ally simulated,  when  cough  is  very  severe  and  paroxysmal,  as 
we  frequently  see  in  hooping-cough,  when  the  fit  is  about  to 
cease.     Indeed,  we  have  seen  a  number  of  instances,  where  the 
effort  of  puking  was  constantly  excited  during  a  long-continued 
spell  of  coughing.   In  these  cases,  had  haemoptysis  been  present, 
it  might  readily  have  been  mistaken  for  haematemesis.     In  the 
former,  however,  there  is  almost  always  cough ;  the  blood  is 
frothy,  and  vermilion-coloured;  in  the  latter,  the  blood  is  black, 
sometimes  fetid,  and  most  commonly  mixed  with  mucus.     It 
generally  takes  place  at  a  much  later  period  of  life  than  the  for- 
mer, and  is  at  times  so  unequivocally  ejected  by  an  effort  of  the 
stomach,  or  so  evidently  mixed  with  some  of  its  contents,  as  to 
leave  no  doubt  upon  the  mind.     If,  therefore,  the  discharge  on 
the  one  hand  be  preceded  by  a  spell  of  coughing,  we  may  be 
pretty  certain  that  the  blood  comes  from  the  lungs;  and  the  con- 
trary. We  must  not  take  for  granted,  however,  that  the  haemor- 
rhagy  is  necessarily  from  the  stomach,  because  blood  or  coagula 
are  observed  in  the  stools;   for  we  have  seen  this  happen  more 
than  once  in  unequivocal  cases  of  haemoptysis. 


H.2EMATEMESIS.  731 


Prognosis. 

3341.  Much  on  this  subject  may  be  learnt,  from  a  knowledge 
of  the  remote  cause ;  thus,  if  the  patient  has  swallowed  any  poi- 
sonous substance ;  if  he  have  received  any  violent  mechanical 
injury  on  the  abdomen,  or  the  region  of  the  stomach ;  if  it  have 
supervened  a  chronic  visceral  disease;  if  the  efforts  be  severe 
and  indomitable,  and  attended  by  large  discharges  of  blood,  and 
this  be  very  fetid,  or  resembling  tar,  the  case  must  always  be 
regarded  as  one  of  great  danger,  but  not  one  of  absolute  hope- 
lessness.    If,  on  the  other  hand,  it  has  followed  a  fit  of  anger,  a 
suppression  of  some  customary  evacuation,  as  the  haemorrhoids, 
the  catamenia,  the  drying  up  of  an  issue,  &c.,  if  the  body  be 
otherwise  sound,  it  is  rarely  fatal. 

Predisposing  and  Determining  Causes. 

3342.  It  is  generally  agreed  that  the  peculiar  character  of  the 
female  constitution,  make  them  more  obnoxious  to  this  disease 
than  males.     Those  who  are  easily  put  in  a  passion  from  slight 
causes,  and  frequently  display  irascibility;  or  who  maybe  power- 
fully affected  by  moral  causes,  are  more  liable  to  haematemesis, 
than  those  of  a  contrary  temperament.     An  indolent,  luxurious 
life  about  the  age  of  puberty ;  chronic  abdominal  affections;  wo- 
men who  are  irregular  in  their  menstrua,  a  continued  use  of 
ardent  spirits,  &c.  all  tend  to  dispose  the  stomach  to  take  on  this 
haemorrhagic  effort. 

3343.  The  determining  causes  may  be  any  thing  which  shall 
embarrass  the  circulation  of  the  blood  in  the  vessels  of  the  sto- 
mach ;  the  suppression  of  menses,  or  other  discharges.   The  sud- 
den application  of  cold  to  the  body  during  perspiration,  poisons, 
powerful  emetics,  or  acrid  preparations  of  mercury;  falls,  blows, 
pressure  upon  the  stomach,  aneurismal  tumours,  &c. 

Symptoms. 

3344.  Previously  to  the  access  of  haematemesis,  the  patient 
experiences  not  only  the  premonitory  symptoms  of  haemorrhagy 
in  genera],  (p.  706,)  but  also  such  as  belong  to  this  particular 
species.     Thus,  anxiety,  lassitude,  uneasiness  about  the  region 
of  the  stomach,  its  distention,  nausea,  and  severe  pain  in  the 
epigastrium — to  these  succeed  others  equally  distressing,  but 
more  decided ;  for  now  blood  is  thrown  up  in  greater  or  less 
quantity;  fluid,  or  coagulated;  pure,  or  mixed  with  some  of  the 
contents  or  products  of  the  stomach.  This  effort  is  accomplished 


732  HJEMATEMESIS. 

with  more  or  less  ease  or  difficulty;  and  this  succeeded  by  more 
or  less  relief.  This  calm  may  however  be  disturbed  by  fresh  re- 
turns of  vomiting,  and  discharges  of  blood  ;  the  intervals  may  be 
longer  or  shorter,  according  to  the  force  and  nature  of  the  excit- 
ing cause.  After  these  spells  of  vomiting,  the  bowels  yield,  and 
give  issue  to  liquid,  and  insupportably  fetid  stools. 

3345.  Fever  rarely  accompanies  this  complaint;  though  the 
pulse  may  be  decidedly  affected,  both  in  its  force  and  frequency; 
sometimes  firm,  at  other  times  feeble,  sometimes  full,  at  other 
times  small,  &c. 

3346.  The  vomiting  spells  continue  to  uncertain  periods,  as 
the  blood  may  be  more  or  less  abundantly  thrown  into  the  sto- 
mach; and  the  renewal  of  each  fresh  effort  is  generally  accompa- 
nied by  symptoms  which  mark  the  progress  of  the  disease,  par- 
ticularly if  the  spells  are  frequently  excited,  and  likely  to  have 
an  unfortunate  termination.     The  stomach  and  left  hypochon- 
drium  becomes  distended ;  the  countenance  is  changed ;  the  face 
pale  ;  the  eyes  hollow;  the  strength  fails;  fainting;  and  presently 
cold  sweats  and  death. 

3347.  If  the  disease  is  disposed  to  a  favourable   issue,   the 
whole  of  the  symptoms  abate  their  intensity;  the  quantity  of 
ejected  blood,  is  found  gradually  to  diminish,  and  mucus  to  sup- 
ply its  place.    The  strength  and  appetite  return,  and  digestion 
is  soon  naturally  and  healthily  performed. 

3348.  Haematemesis  may  however  terminate  in  some  hopeless 
and  distressing  chronic  affection;  such  as  dropsy,  hectic,  chronic 
inflammation,  &c. 

Treatment. 

3349.  This  will  necessarily  divide  itself  into,  1st,  what  may 
be  proper  during  the  continuance  of  the  vomiting;  and  2d,  what 
may  be  necessary  in  the  intervals. 

3350.  1st.  It  is  every  way  important  to  the  relief  of  this  dis- 
ease, that  we  ascertain  when  practicable,  the  remote  cause  which 
has  produced  it.     If  it  arise  from  substances  taken  into  the  sto- 
mach, their  nature  should  be  taken  into  consideration,  that  they 
may,  if  they  are  chemical,  be  decomposed  if  possible;  or  the  irri- 
tation diminished,  if  they  are  acrid.  These  cases  must  be  treated 
as  the  various  poisons  may  require. 

3351.  If  it  proceed  from  no  evident  cause,  and  the  system  ac- 
tive, we  have  reason  to  fear  inflammation,  from  the  almost  cer- 
tain existence  of  congestive  irritation.     In  this  case,  blood  must 
be  abstracted  from  the  arm,  if  the  force  of  the  pulse  justify  the 
measure;  if  not,  from  the  epigastrium,  by  leeches  or  cupping.  The 
bowels  should  be  immediately  opened  by  a  stimulating  injec- 


HJfiMATEMESIS.  733 

tion,*  and  if  the  feet  and  legs  be  cold,  they  should  be  placed  in 
the  mustard  bath,  (par.  3277,)  or  have  sinapisms  applied  to  them. 
The  drinks  should  be  of  the  mucilaginous  kind,  as  flaxseed  tea, 
slippery-elm  bark  tea,  barley  water,  rice  water,  gum  Arabic 
water.  Dry  cupping,  blisters,  or  sinapisms  to  the  region  of  the 
stomach  may  be  also  necessary;  especially  if  the  vomiting  be 
obstinate,  and  the  pulse  has  become  feeble.  At  this  time,  much 
advantage  may  be  found,  from  an  enema  with  laudanurn,t  as  it  will 
tranquillize  the  stomach,  and  abate  general  suffering.  The  bleed- 
ing must  be  repeated  if  the  pulse  keep  strong,  or  if  the  com- 
plaint be  regulated  by  a  periodical  febrile  movement;  or  in  other 
words,  the  paroxysms  must  bs  treated  upon  the  same  general 
principles  as  regulate  the  treatment  of  intermittents.  Besides 
these  general  notions  of  the  management  of  this  case,  attention 
should  be  paid  to  the  species  of  this  complaint,  as  constant  re- 
ference should  be  made  to  the  cause — thus  we  would  not  treat 
the  constitutional  haematemesis,  like  the  accidental,  &c.  Dr. 
Chapman  is  equally  convinced  of  the  propriety  of  giving  an  eme- 
tic in  this  disease,  as  in  the  other  haemorrhagies  spoken  of  before. 
Of  this  plan,  we  can  say  nothing  from  our  own  experience,  hav- 
ing never  tried  the  remedy  but  in  one  instance ;  but  in  this  it  did 
not  benefit  the  patient — this,  we  had  afterwards  reason  to  believe, 
was  a  case  of  splanchnic  haematemesis ;  in  which  we  would  not 
advise  this  remedy;  in  the  other  forms,  the  same  objections  do 
not  attach ;  for  nothing  but  palliatives  can  be  useful  in  the  symp- 
tomatic form  of  ha3matemesis. 

3352.  2d.  It  is  not  sufficient  for  the  welfare  of  the  patient, 
that  we  arrest  the  discharge  of  blood  from  the  stomach  for  the 
time  being;   our   endeavours   should  extend  beyond  this — we 
should  aim  at  preventing  a  return.    For  this  purpose  much  will 
be  required  from  the  physician,  and  more  from  the  good  sense 
and  moral  courage  of  the  patient  himself.     For  it  would  be  vain 
for  the  physician  to  lay  down  proper  rules,  if  the  patient  will 
not  strictly  conform  to  them. 

3353.  We  would  in  all  cases  of  this  kind  recommend  the  most 
strict  rules  of  diet — nothing  stimulating  or  indigestible  should 
be  taken  into  the  stomach;  on  the  contrary,  the  most  bland,  (par. 
3272,)  should  be  persevered  in,  until  such  a  condition  of  stomach 
is  acquired,  as  will  profit  sooner  or  later  by  a  more  generous 
regimen — but  let  the  patient  obtain  the  leave  of  his  physician 
before  he  venture  upon  a  change. 

3354.  The  bowels  should  be  kept  open  by  artificial  means,  if 
they  require  to  be  urged — for  this  purpose  the  simple  rhubarb 

*  For  this  purpose  nothing  answers  better  than  a  large  table-spoonful  of 
common  salt,  dissolved  in  a  pint  of  warm  water. 

•f  A  gill  of  water,  and  sixty  or  seventy  drops  of  laudanum. 


734  H-EMATURTA. 

pill  will  be  found  to  answer  best;  unless  it  be  a  case  depending 
upon  suppressed  haemorrhoids;  then,  the  addition  of  aloes  will 
be  important. 

3355.  Exercise  should  not  be  neglected ;  especially  by  such 
as  have  no  visceral  lesions  to  contend  with.     If  the  strength  has 
suffered  much,  tonics  may  be  required ;  but  they  should  not  be 
of  the  stimulating  kind — the  mild  vegetable  bitters,  and  the  sul- 
phuric acid  will  answer  best. 

3356.  We  must  never  lose  sight  of  the  remote  causes  of  this 
complaint;  for  unless  they  be  removed,  we  cannot  expect  to  con- 
quer this  affection.    Therefore  in  females,  regard  must  be  paid 
to  their  menses — if  obstructed,  our  first  endeavour  should  be  to 
restore  them ;  and  so  on,  with  the  other  evident  causes. 

SECT.  IV. — HJEMATURIA,  OR  VOIDING  BLOODY  URINE. 

3357.  This  disease  is  one  of  rare  occurrence,  either  in  an  idio- 
pathic  or  symptomatic  form ;  but  more  especially  the  former. 
This  fact  would  excite  our  wonder  more,  did  we  not  constantly 
seem  to  forget,  either  the  anatomy  or  physiology  of  the  organs 
from  which,  at  least,  one  species  of  this  disease  proceeds — namely, 
the  kidneys.     The  extreme  vascularity  of  these  organs,  and  the 
severe  duties  they  are  destined  to  perform,  render  them  liable  to 
all  the  mischances,  that  such  organization,  and  functions,  are  sub- 
ject to.   The  quantity  of  blood  which  passes  through  these  glands, 
is  calculated  to  be  one-sixth  of  the  whole  mass ;  and  the  quantity 
of  fluid  it  separates  from  it,  is  under  the  best  circumstances  of 
health  very  great;  but  under  some  forms  of  disease,  it  is  truly 
enormous.     When  we  consider  these  circumstances,  we  are  only 
astonished,  that  the  disease  in  question  is  not  of  more  frequent 
occurrence  than'  we  really  find  it;  for,  as  we  have  stated,  the 
idiopathic  form  of  hsematuria,  is  rarely  met  with. 

3358.  Frank  tells  us,  that  of  four  thousand  patients  with  se- 
rious diseases  admitted  into  the  Clinical  Institute  of  Pavia,  in 
ten  years,  there  were  but  ten  afflicted  with  idiopathic  haematuria. 
Of  1913  patients  that  he  prescribed  for  in  a  similar  institution  at 
Vienna,  in  the  course  of  seven  years,  there  was  but  one  case  of 
haematuria.  And  of  13,647  deaths  in  the  General  Hospital  of  the 
same  city,  there  was  not  one  of  haematuria.     He  says  however, 
that  to  understand   why  haematuria  is  so  rare,  we  must  be  ap- 
prized, that  he  has  not  confounded  it  with  haemorrhages  of  the 
ureters,  haemorrhoides  of  the  bladder,  nor  with  haemorrhage, 
from  any  other  cause,  that  may  proceed  from  this  organ — in  a 
word,  he  confines  the  disease,  in  his  account  of  haematuria,  to  a 
flow  of  blood  from  the  kidney  or  kidneys  themselves.     But  in  a 
practical  point  of  view,  this  limitation  is  neither  necessary,  nor 
useful. 


H.EMATURIA.  735 


Definition. 

3359.  Haematuria  is  a  flowing  of  pure  blood,  generally  fluid, 
but  sometimes  coagulated,  or  mixed  with  the  urine  in  a  greater 
or  smaller  proportion,  and  discharged  by  the  urethra — it  may  be 
red,  dark,  black,  or  only  bloody,  yielded  by  the  kidneys,  the 
ureters,  or  the  bladder. 

3360.  This  disease  may  be  either  idiopathic,  or  symptomatic. 
The  first  form,  as  we  have  just  stated,  is  very  rare ;  the  latter 
much  more  frequent.     The  idiopathic  may  proceed,  from  an  en- 
gorged state  of  the  kidneys,  as  generally  happens,  in  every  other 
kind  of  haemorrhage;  a  vessel  giving  way  in  this  instance,  will 
constitute  haematuria ;  and  consequently,  may  be  useful,  if  not 
excessive,  or  it  may  be  hurtful,  by  its  excess.     This  engorged 
state  of  the  kidney,  may  proceed  from  any  cause  capable  of  di- 
recting an  unusual  flow  of  blood  to  this  organ  ;  as  the  congestive 
stage  of  fever;  calculous  concretions ;  diuretics  unduly  urged,  or 
of  too  great  power ;  as  all  the  terebinthinate  substances ;  canthari- 
des ;  Harlaem  oil,  &c.     The  symptomatic,  may  arise  from  cer- 
tain fevers,  as  the  putrid,  as  it  is  called ;  small-pox,  measles,  and 
in  a  very  recent  instance,  it  proceeded  from  scarlatina;  affections 
of  the  bladder;  as  inflammation  either  active  or  chronic  of  the 
mucous  coat;  vascular  tumours  within  the  bladder;  a  scirrhous 
condition  of  this  organ,  or  the  ureters,  &c.     We  know  of  one  in- 
stance in  which  it  appeared  to  be  produced  by  a  suppression  of 
the  menses;  in  this  instance  its  return  was  periodical,  and  seem- 
ed to  obey  the  menstrual  interval,  and  did  so  until  the  menses 
were  restored.  Suppressed  haemorrhoidal  discharge  has  also  been 
followed   by  haematuria.     In  many  instances,  this  affection  is 
really  brought  on,  after  it  has  been  once  established — any  over- 
exertion,   or  violence,   will  produce  it;  and  perhaps  nothing 
sooner  than  jolting  over  rough  roads,  or  riding  a  rough  trotting 
horse. 

Symptoms. 

3361.  The  symptoms  which  attend  hssmaturia,  will  vary  in  a 
certain  degree,  as  the  haemorrhage  may  be  from  the  kidneys,  the 
ureters,  or  the  bladder. 

Renal  Hsematuria. 

3362.  In  the  first  variety,  there  is  very  little  pain,  unless  the 
disease  be  caused  by  the  mechanical  irritation  of  a  calculus.   The 
most  that  is  observed,  is  a  dull  sensation,  and  tension  in  the  re- 


736  HJEMATURIA. 

gion  of  the  kidneys;  a  slight  fever,  a  general  heaviness  and  las- 
situde. The  blood  for  the  most  part  flows  freely;  is  of  a  ver- 
milion hue,  and  accompanies  the  urine.  If  it  proceed  from  a  cal- 
culus, the  sufferings  are  sometimes  great — a  dull  distressing  sen- 
sation is  felt  in  the  seat  of  the  kidneys,  attended  by  frequently 
repeated  lancinating  pains  in  the  course  of  the  ureter,  from  the 
kidney  to  the  bladder  ;  retraction  of  the  testicle  in  the  male,  and 
shooting  pains  down  the  thighs,  in  the  female;  more  or  less  fe- 
ver; thirst,  nausea,  and  vomiting. 

Haematuria  of  the  Ureter. 

3363.  In  the  second  variety,  the  symptoms  are  much  the  same 
in  most  instances ;  except  that  the  blood  flows  in  much  smaller 
quantities;  owing  to  the  vessels  of  this  duct  being  much  less. 
The  pain  is  principally  felt  during  the  discharge  of  urine,  and 
follows  the  course  of  the  ureter  from  the  point,  of  irritation,  to 
the  bladder.     Should  a  calculus  be  the  cause  of  irritation,  it  may 
excite  inflammation,  which  may  terminate  in   the  formation  of 
pus,  and  this  may  be  evacuated  with  the  urine — this  is  a  much 
more  aggravated  case,  than  when  the  flow  of  blood  proceeds 
from  mere  engorgement  of  the  ureter,  and  one  much  more  likely 
to  be  followed  by  serious  consequences. 

3364.  Frank  in  treating  this  subject,  gives  a  very  rational 
and  satisfactory  explanation  of  the  formation  of  the  substances 
expelled  from  the  urethra  in  both  these  varieties  of  haematuria, 
and  which  have  been  gravely  given  as  cases  of  the  expulsion  of 
worms  from  the  bladder. 

3365.  He  says,  "  lorsque  le  sang  fourni  par  les  reins  ou  par 
les  ureteres  ne  peut  parvenir  dans  la  vessie,  il  se  coagule  et  forme 
de  caillots  irreguliers  ou   cylindriques,  des  polypes  alonges  et 
minces  qui  ressemblent  a  des  vers  ascarides,  et  presente  unecou- 
leur  brune,  noiratre,  ou  d'un  blanc  jaunatre.     Ces  polypes  ob- 
struent completement  les  conduits;  quelquefoisl'urinelescreusant 
dans  leur  partie  moyenne,  ils  deviennent  tubuleux,  et  permet- 
tent  le  passage  a  ce  liquide.     Ils  parviennent  sous  1'une  et  sous 
1'autre  forme  dans  la  vessie,  sortent  par  Furetre,  et  en  imposent 
aux  personnes  qui  ignorent  ce  phenomene,  pour  des  vers  renaux 
ou  vesicaux.     Lorsque  le  sang  rencontre  un  obstacle  pres  de  la 
vessie,  1'uretere  se  dilate  au-dessus,  son  diametre  devient  quelque- 
fois  triple,  il  egale  meme  celui  de  1'intestin  grele,  comme  nous 
avons  eu  occasion  de  1'observer." 

Haematuria  of  the  Bladder. 

3366.  In  the  third  variety,  the  blood  proceeds  directly  from 


H.EMATURIA.  737 

the  bladder;  and  this  organ  being  unaccustomed  to  the  presence 
of  blood  within  its  cavity,  becomes  highly  irritated.  This  is  the 
case,  whether  the  blood  which  occupies  the  bladder  proceeds 
from  its  own  engorged  parietes,  or  is  received  from  the  kidneys, 
or  the  ureters,  the  irritation  and  disturbance  is  the  same.  This 
gives  rise  to  a  pain  confined  to  the  region  of  the  bladder,  caused. 
by  the  presence  of  the  urine  and  blood,  when  these  are  even  in 
small  quantities ;  frequent  desire  to  void  it  will  necessarily  fol- 
low; dysury,  tension,  heat  in  the  hypogastrium.  The  urine 
after  standing,  is  found  to  contain  a  viscid,  puriform,  and  of- 
fensive matter,  which  settles  to  the  bottom  of  the  vessel  in 
which  it  is  received.  To  this  follows  nausea,  vomiting,  faint- 
ness,  cold  sweats,  a  weak  and  frequent  pulse.  The  blood  ren- 
dered with  the  urine,  is  small  in  quantity,  and  is  of  a  dull  or 
black  colour.  The  discharges  may  occasionally  be  looked  upon 
as  critical.* 

3367.  After  the  bladder  is  thus  emptied,  the  greater  part  of 
the  symptoms  just  named  become  less  intense;  the  urine  flows 
clearer,  and  with  more  ease ;  unless  a  clot  of  blood  should  sud- 
denly form  at  the  neck  of  the  bladder,  and  excite  this  organ  to 
painful  efforts  to  expel  it.     The  hsematuria  of  the  bladder  is  not 
always,  however,  attended  by  symptoms  so  severe  as  those  just 
stated ;  for  the  blood  will  sometimes  flow  freely  from  the  blad- 
der, unaccompanied  by  any  unpleasant  sensation.     We  may 
nearly  always  detect  the  presence  of  blood  in  the  urine,  by  its 
forming  a  kind  of  coagulum  at  the  bottom  of  the  vessel. 

Prognostic. 

3368.  As  regards  the  issue  of  hsematuria,  much  will  depend 
upon  the  nature  and  force  of  the  remote  cause.     Should  the  dis- 
ease be  caused  by  calculi  or  stone  either  in  the  kidney  or  blad- 
der, much  may  be  apprehended,  as  we  cannot  limit  the  extent 
and  frequency  of  the  irritation,  nor  with  certainty  remove  the 
offending  cause.      If  it  be  a  symptom  attached  to  any  other 
disease,  the  degree  of  danger  will  be  in  proportion  to  the  risk 
occasioned  by  the  disease  of  which  it  is  a  symptom — as  small- 
pox, typhus,  &c.;  or  if  caused  by  a  chronic  a/Fection,  the  same 
may  be  said,  but  it  will  not  perhaps  be  so  violent,  but  may  be  of 
longer  continuance.  As  a  general  rule,  this  affection  may  not  be 
looked  upon  as  highly  threatening,  unless  the  disease  with  which 

*  Frank  mentions  a  curious  circumstance  connected  with  the  transfusion  of 
blood;  and  if  it  be  not  altogether  accidental,  it  deserves  the  attention  of  both 
the  pathologist,  and  physiologist.  He  says,  "  in  fifty  animals  that  were  sub- 
jected to  the  experiment  of  transfusion,  twenty  were  attacked  with  a  discharge 
of  bloody  urine." 

93 


738  H.EMATURIA. 

it  is  associated  be  in  itself  incurable.  When  it  depends  upon  the 
suppression  of  some  other  discharge,  upon  plethora,  violent  exer- 
cise, temporary  excesses,  or  debauch ;  when  the  quantity  of  blood 
rendered  is  small  in  quantity,  and  its  returns  not  too  frequent, 
we  may  expect  the  disease  will  disappear  by  proper  treatment. 

3369.  But  when  it  happens  to  old  people,  or  such  as  have  ex- 
hausted constitutions,  though  the  discharge  itself  may  not  from 
its  quantity  appear  threatening,  yet  there  is  no  security  against 
a  clot  of  blood,  formed  within  the  kidneys  or  bladder,  becoming 
a  nucleus  for  a  stone,  in  either  of  these  places.     Or  should  it  be 
excessive  or  very  frequently  repeated,  it  may  like  other  haemor- 
rhages, cause  extreme  debility,  or  dropsy. 

Treatment. 

3370.  The  safest  and  most  simple  mode  of  treating  haematu- 
ria,  is  to  view  it  like  an  hsernorrhagy  from  any  other  organ  or 
surface  of  the  body ;  and  be  guided  by  the  same  indications  as 
present  themselves  upon  any  other  similar  occasions.     That  is, 
if  the  patient  be  plethoric,  bleeding,  leeching,  and  cupping  should 
be  resorted  to ;  if  the  pulse  be  very  active,  an  adequate  quantity 
of  blood  should  be  drawn  from  the  arm ;  if  the  pulse  be  less  ac- 
tive, and  not  indicate  a  necessity  for  this  general  abstraction  of 
blood,  leeching  or  cupping  immediately  from  over  the  kidneys 
should  be  resorted  to,  and  repeated  if  necessary.     Rest  of  body, 
and  tranquility  of  mind,  should  be  enjoined;  the  patient  should 
sleep  upon  a  matrass,  instead  of  a  feather  bed,  and  his  lower  ex- 
tremities should  be  kept  warm.     The  bowels  should  be  opened 
by  either  of  the  neutral  salts,  and  a  strict  antiphlogistic  regimen 
should  be  observed.     All  exertion  should  be  prohibited,  such  as 
lifting  weights,  &c. 

3371.  Should  the  pulse,  however,  not  betray  febrile  excite- 
ment, or  plethoric  fulness,  bleeding  need  not  be  employed,  either 
generally  or  locally,  unless  pain  is  felt  in  the  region  of  the  kid- 
neys.    In  this  case,  much  benefit  is  derived  from  topical  deple- 
tion.    In  feeble  habits,  and  inleucophlegmatic  patients,  mild  as- 
tringents are  highly  useful — among  these,  the  infusion  of  red 
rose  leaves  is  we  believe  the  best  of  this  class.*     It  should  be 
continued  for  several  days  together.    The  next  in  quality,  is  the 
extract  of  rhatany.t     The  sugar  of  lead  has  been  recommended, 
but  we  cannot  speak  of  its  powers  from  our  own  experience. 

•  R.  Fol.  rosae.  rub.  §ss.  Take  red  rose  leaves,  half  an  ounce.  A  pint 
of  boiling  water  to  be  poured  upon  them  and  allowed  to  stand  until  cold — strain 
off  as  wanted.  A  wine-glassful  every  two  or  three  hours. 

f  R.  Ext.  rhatan.  gij.  Take  extract  of  rhatany,  2  drachms,  f.  pil.  xl.  Two 
every  two  or  three  hours. 


RHEUMATISM.  739 

Ten  grains  of  Dover's  powder  at  bed-time,  we  have  thought 
highly  useful.  The  muriated  tincture  of  iron  in  ten  or  twenty 
drop  doses  three  times  a  day  Dr.  Eberle  extols  very  much.  He 
also  recommends  a  combination  of  alum  and  ipecacuanha.*  If 
the  bleeding  be  caused  by  a  calculus  in  the  kidney  or  bladder, 
recourse  must  be  had  to  opium  if  the  pulse  will  bear  it ;  the  warm 
bath,  and  topical  depletion  from  over  the  kidneys  by  cupping  or 
leeching. 

3372.  The  patient  should  drink  freely  of  demulcent  drinks — 
such  as  gum  Arabic  water,  flaxseed,  or  watermelon-seed  tea ; 
barley  water,  slippery-elm  bark  tea,  &c.  All  diuretics,  as  squills, 
nitre,  &c.  should  be  withheld. 


CHAPTER  XV. 

RHEUMATISM. 

3373.  DR.  SCUDAMORE  defines  rheumatism,  a  "pain  of  a  pe- 
culiar kind,  usually  attended  with  inflammatory  action,  affecting 
the  white  fibrous  textures  belonging  to  muscles  and  joints,  such 
as  tendons,  aponeuroses,  and  ligaments ;  the  synovial  membrane 
of  the  bursae  and  tendons ;  and  nerves ;  occasioned  by  variable 
temperature,  or  by  direct  cold  or  moisture,  "t 

3374.  He  divides  this  disease  into  two  species,  "  acute  and 
chronic;"  the  former  he  subdivides  into  "the  acute,  and  sub- 
acute." 

3375.  The  acute,  is  thus  characterized,  "pain  with  inflamma- 
tion of  the  ligaments  of  the  joints,  and  usually  those  of  the  larger 
joints ;  or  of  tendons  and  aponeuroses ;  of  the  sheaths  of  tendons; 
of  bursal  membranes ;  and  of  nerves ;  aggravated  by  motion ;  for 
the  most  part  attended  with  external  redness  of  a  bright  red  co- 
lour; and  with  fever  which  has  exacerbations,  and  sometimes  dis- 
tinct remissions ;  with  copious  partial  perspirations,  commonly 
of  an  acid  odour ;  and  high-coloured  urine,  depositing  abundantly 
lateritious  sediment." 

3376.  The  definition  just  given  is  certainly  comprehensive, 
and  much  more  satisfactory  than  that  of  Dr.  Cullen — yet,  it  must 
still  remain  doubtful,  whether  the  seats  of  the  affection  are  strictly 

*  Pulv.  aluminis.  gj.  ipecac.  Qj.  M.  div.  in  x.     One  every  morning,  noon, 
and  evening, 
•j-  Treatise  on  the  Nature  and  Cure  of  Rheumatism,  &c.  p.  11. 


740  RHEUMATISM. 

represented  by  those  laid  downln  the  definitions;  as  it  seems  that 
almost,  if  not  every  structure  is  occasionally  the  seat  of  rheuma- 
tism. While  on  the  other  hand,  the  morbid  changes  produced 
by  rheumatism,  even  where  it  has  been  bith  long-continued  and 
severe,  have  not  been  in  general  so  unequivocal,  as  always  to 
point  out  this  inflammation  as  the  cause  of  them  ;  as  the  muscular 
fibres,  the  bones,  &c.  are  said  to  be  liable  to  this  disease. 

Symptoms. 

3377.  This  disease,  like  other  phlegmasise,  is  usually  ushered 
in  by  a  sensation  of  cold,  and  sometimes  by  a  chill  of  some  con- 
tinuance; we  once  knew  it  to  continue  for  more  than  an  hour, 
and  was  supposed  to  be  the  forerunner  of  an  intermittent;  at 
other  times,  slight  and  repeated  shivering  mark  its  commence- 
ment.    The  heat  which  succeeds  the  coldness  does  not  always 
extend  over  the  whole  body — we  have  known  it  to  be  confined 
to  the  upper  portions  of  the  body,  or  such  as  were  nearest  to  the 
source  of  circulation,  while  the  feet  and  legs  have  remained  cold, 
though  portions  of  these  parts  afterwards  became  the  seats  of  the 
affection.     At  other  times  a  general  soreness  or  rigidity  of  the 
whole  muscles  of  the  body  would  announce  the  complaint,  espe- 
cially in  those  who  are  liable  to  the  disease.     We  have  known 
head-ache,  and  a  deranged  state  of  the  stomach  to  be  the  fore- 
runners of  rheumatism;  sometimes  nausea  and  vomiting  of  a 
bitterish  acid  fluid,  would  accompany  the  head-ache,  &c. ;  this 
would  especially  happen  when  this  disease  has  been  provoked 
by  some  little  excess  in  eating  or  drinking. 

3378.  Soon  after  these  premonitory  or  constitutional  symp- 
toms show  themselves,  some  one  portion  of  the  body,  to  a  greater 
or  less  extent,  would  become  affected  with  pain;  and  as  the  lower 
extremities  are  more  liable  to  these  attacks  than  the  other  parts 
of  the  system,  the  ankles  and  knees  are  generally  selected  for  the 
local  affection.     Pain,  swelling,  and  redness  now  show  them- 
selves ;  and  the  degree  of  either  appears  to  depend,  according  to 
Scudamore,  upon  the  tissue  involved.  "If  the  bursse  be  the  seat 
of  inflammation,  there  is  considerable  swelling,  but  scarcely  any 
discoloration  of  the  skin,  and  sometimes  not  the  slightest  altera- 
tion in  this  particular.    If  the  tendons  and  ligaments  be  affected, 
there  is  more  or  less  redness  of  the  surface,  which  is  usually  of 
a  vivid  colour,  and  is  often  in  patches.     When  the  tendons  are 
inflamed,  their  sheaths  are  excited  to  increased  secretion,  and 
they  are  found  distended."  p.  20. 

3379.  The  hips,  thighs,  or  back,  may  also  be  the  primary  lo- 
cation of  rheumatism,  and  from  either  it  may  extend  with  more 
or  less  rapidity  to  other  portions  of  the  body,  or  it  may  confine 


RHEUMATISM.  741 

itself  to  the  part  it  originally  seized.  The  attack  may  be  more 
or  less  sudden,  or  more  or  less  extensive  and  severe.  We  re- 
member a  highly  respectable  clergyman,  in  the  year  1792,  from 
a  very  sudden  check  of  perspiration,  after  being  much  heated  by 
severe  bodily  exercise,  becoming  in  a  few  hours  immoveable  in 
his  bed ;  for  every  portion  of  the  body  participated  largely  in 
the  affection.  Or  it  may  attack  a  single  portion  of  the  body,  and 
have  to  follow  it,  nearly  a  similar  disability  to  move.  Villeneuve 
says  he  saw  a  joiner  suddenly  seized  with  lumbago,  which  rivet- 
ted  him  to  the  spot,  being  incapable  of  any  kind  of  motion.* 

3380.  Fever,  to  a  greater  or  less  degree,  becomes  fixed ;  it 
has  remissions,  but  rarely  intermissions — the  remission  for  the 
most  part,  does  not  take  place  until  towards  morning,  and  after 
the  patient  has  passed  a  wretched  night;  for  pain  is  commonly 
in  proportion  to  the  degree;  or  rather  perhaps  in  this  acute  form 
it  may  be  said  that  fever  is  in  proportion  to  pain  ;  and  this  pain, 
is  constantly  found  to  be  worse  at  night.   The  occasional  increase 
of  pain  in  rheumatism,  is  in  various  degrees,  but  is  almost  always 
fluctuating  from  one  extreme  to  another;  sometimes  sudden  and 
lancinating  like  an  electric  shock;  at  others,  pulsating,  obtuse, 
and  gnawing,  as  if"  the  flesh  were  torn  from  the  bone  by  dogs," 
&c.    For  the  most  part,  the  articular  portions  of  the  limb,  when 
a  limb  is  the  affected  part,  is  more  painful  than  the  other  por- 
tions, and  oftentimes  it  is  confined  to  it.     It  is  always  increased 
by  attempts  to  move  the  limb  or  joint.    Sydenham  has  remarked, 
that  the  pain  increased  sometimes  after  the  fever  had  abated. 
Some  have  thought  that  women  suffer  more  than  men  in  attacks 
of  rheumatism ;  and  that  this  disease  in  hot  climates,  suffers  no 
abatement  of  intensity. 

3381.  The  pulse  in  rheumatic  fever  is  almost  always  hard  and 
full  in  the  beginning;  but  the  hardness  diminishes,  as  soon  as 
sweating  takes  place — it  may  then  be  said  to  be  soft,  owing  per- 
haps to  the  greater  fulness  or  dilatation  of  the  artery.     There  is 
generally,  a  peculiar  quickness  in  the  stroke  of  the  rheumatic 
pulse,  which  is  not  always  combined  with  frequency — we  have 
a  patient  at  this  moment,  in  which  this  peculiarity  exists  in  a  re- 
markable degree,  and  this  took  place  as  soon  as  the  perspiration 
became  profuse. 

3382.  The  heat  of  the  skin  is  almost,  always  increased ;  or 
rather  it  seems  to  keep  pace  with  the  fever.  It  is  pretty  equally 
diffused  over  the  body,  though  rather  greater  in  the  affected  parts. 
The  heat  is  of  a  peculiar  character;  it  is  sharp  and  burning;  and 
resembles  the  sensation  of  heat  given  by  a  hot  fire;  nor  is  it  dimi- 
nished by  sweat  breaking  out,  as  in  ordinary  autumnal  fevers; 

•  Diet.  <Jes  Scien.  Med.  Vol.  48,  p.  484. 


742  RHEUMATISM. 

nor  does  the  patient,  except  in  a  very  few  instances,  feel  the 
least  relief,  however  profuse,  or  long-continued  this  may  be.  In- 
deed, in  some  instances  it  seems,  that  the  patient  is  not  much 
relieved  until  these  sweats  diminish,  or  cease  altogether;  they 
therefore  cannot  be  looked  upon  as  critical ;  and  certain  it  is,  as 
we  have  often  had  occasion  to  observe,  that  little  or  no  risk  is 
run,  by  occasional  exposure  of  the  body  to  the  air,  during  this 
period.* 

3383.  When  rheumatism  exists  with  any  intensity,  there  is 
always  more  or  less  swelling  takes  place  in  the  parts  affected — 
this  is  more  remarkable  however  in  the  smaller,  than  in  the 
larger  articulations;  hence  we  find  the  hands  and  feet  more 
swelled  than  the  ankles,  knees,  or  elbows.  This  swelling  is  said 
to  arise  from  a  sudden  effusion  of  lymph,  or  serum  in  the  cellu- 
lar membrane;  and  is  thought  to  afford  relief.     This  may  be  so, 
when  the  swelling  is  occasioned  by  the  pouring  out  of  serum, 
but  not  so  when  lymph  is  yielded;  for  we  have  seen  every  symp- 
tom aggravated  after  swelling  has  taken  place.     The  first  may 
be  known,  by  the  part  retaining  the  print  of  the  finger  when 
pressure  is  made ;  while  the  latter  is  firmer  and  is  elastic.     It 
seems  to  require  a  more  exalted. state  of  inflammation  to  pour 
out  lymph,  than  to  effuse  serum. 

3384.  Acute  rheumatism  is  almost  always  attended  by  redness 
in  parts  affected ;  but  this  is  not  constant,  nor  is  it  always  equal 
in  intensity.     Much  of  this  however  will  depend  upon  the  se- 
verity of  the  case,  the  parts  affected,  and  the  degree  of  swelling. 
If  the  internal  inflammation  be  great,  the  skin  will  be  propor- 
tionably  involved,  unless  the  disease  be  very  deep-seated.     For 
we  have  seen  an  entire  limb  from  the  hip  to  the  toes,  severely 
affected  by  rheumatism  ;  on  the  thigh  there  was  no  discoloration, 
nor  was  there  any  on  the  thick  part  of  the  leg ;  but  the  hip, 
(immediately  over  the  trochanter,)  the  knee,  ankles,  and  toes, 
were  very  red.     If  the  parts  affected  be  but  thinly  covered,  by 
other  structure,  there  will  almost  always  be  redness,  as  about  the 
knee,  and  ankle  joints,  &c.  and  the  swelling  may  be  very  great; 
in  which  case  the  redness  may  be  prevented  by  the  distention. 

3385.  One  of  the  most  remarkable  features  of  rheumatism  is 
its  liability  to  metastasis;  though  much  less  so  than  gout.     It 
rarely  happens,  that  the  acute  form,  remains  stationary  as  regards 


*  According  to  the  experiments  of  Anselmino  upon  the  nature  and  compo- 
sition of  sweat  and  insensible  perspiration,  which  gained  the  prize  offered  by 
the  Heidleberg  Medical  Faculty,  the  sweat  of  a  person  who  had  been  long 
labouring  under  rheumatic  fever  was  the  same  as  common  sweat.  But  that  the 
critical  sweat  of  a  person  labouring  under  acute  rheumatism,  contained  albu- 
men, and  the  product  of  its  distillation  was  alkaline.  The  day  after  the  crisis, 
however,  the  sweat  contained  no  albumen. 


RHEUMATISM.  743 

the  affected  part  during  the  whole  progress  of  the  disease;  nor 
can  we  by  any  process  of  reasoning,  or  deduction  from  cases,  an- 
ticipate when  this  is  about  to  take  place,  or  what  part  it  will  se- 
lect for  its  new  habitation ;  for  it  is  not  regulated  by  proximity, 
size,  nor  similarity,  though  structure  may  have  some  influence — 
but  this  is  by  no  means  constant.  In  the  case  alluded  to  above, 
we  say  the  translation  was  made  to  the  opposite  limb  and  pre- 
cisely to  the  same  extent.  In  this  case,  the  lady  found  the 
change  to  be  complete  in  the  course  of  a  night— and  the  newly- 
besieged  limb,  was  more  painful,  than  the  one  from  which  it  was 
transmitted,  at  the  moment  the  change  began.  And  what  may 
be  considered  remarkable  in  these  changes,  is,  that  the  interme- 
diate parts  suffer  no  inconvenience  during  the  translation. 

3386.  We  have  noticed,  that  fever  of  more  or  less  intensity, 
always  accompanied  the  acute  form  of  rheumatism ;  this  for  the 
most  part  gradually  augments,  with  the  increase  of  the  local  affec- 
tions.   We  have  also  observed,  that  the  pain  was  severer  during 
the  night,  than  in  the  day,  for  a  remission  is  pretty  sure  to  take 
place,  towards  the  morning.    This  fever,  however  exasperated, 
is  never,  as  far  as  we  have  observed,  attended  with  the  same  ex- 
tent of  disturbance  of  the  system,  as  from-  the  same  apparent 
degree  of  fever,  of  the  intermittent  or  remittent  form.     It  is 
nevertheless  evident,  that  it  is  attended   almost  always,  with 
pretty  strongly-marked  gastric  alterations;   thus  thirst,  white 
tongue,  loss  of  appetite,  and  constipation,  are  very  constantly 
present. 

3387.  Delirium  is  a  rare  attendant  as  far  as  we  have  observed 
in  this  disease;  the  intellectual  faculties,  may  however  occasion- 
ally suffer,  more  or  less ;  there  is  usually  great  anxiety,  with 
almost  an  entire  loss  of  sleep,  or  a  constant  watchfulness,  that  does 
not  seem  to  arise  altogether,  from  the  continued  existence  of  pain. 

3388.  Respiration  is  never  directly  affected,  (that  is,  the  lungs 
themselves  do  not  appear  to  be  a  seat  for  rheumatism,)  but  it 
may  become  so,  in  consequence  of  the  disease  fixing  itself  upon 
the  intercostal  muscles,  or  diaphragm.    We  have  seen  respiration 
almost  suspended  when  this  affection  has  fixed  itself  on  either  of 
these  parts,  from  a  sudden  metastasis. 

3389.  The  secretions  from  both  the  skin  and  kidneys  are 
sometimes  much  increased;  sweat,  we  have  remarked,  is  often- 
times very  abundant  in  rheumatism,  without  being  critical,  but 
in  very  few  instances.     Its  smell  is  acid,  and  peculiar;  so  much 
so,  as  almost  to  characterize  the  disease.    The  urine  is  for  the 
most  part  red  in  the  beginning,  and  not  very  abundant,  while  the 
sweating  continues  to  be  profuse — it  however  rather  increases  as 
the  disease  advances ;  but  when  upon  the  decline,  it  deposits  a 
lateritious  sediment.    The  urine  is  sometimes  very  dense,  and 


744  RHEUMATISM. 

very  high-coloured;  resembling  a  mixture  of  blood  and  urine; 
but  we  have  never  seen  this  but  upon  two  occasions  ;  once  in  a 
female,  and  the  other  in  a  male — in  both  instances  they  appeared 
to  be  critical.  In  the  female,  the  region  of  the  kidneys  was  the 
seat  of  the  disease ;  in  the  male,  it  extended  over  nearly  the 
whole  body.  It  has  been  remarked  by  a  number  of  authors,  that 
the  face  has,  in  many  severe  cases,  a  peculiarly  greasy,  and 
shining  appearance. 

3390.  It  seems  to  be  pretty  generally  agreed,  that  a  natural 
condition  of  the  skin,  that  is,  a  freedom  from  huskiness,  and  an 
exemption  from  sweat,  is  an  essential  condition  to  recovery.     If 
with  this  change  in  the  state  of  the  skin,  there  be  a  correspond- 
ing alteration  in  the  pulse  and  tongue,  the  first  becoming  softer, 
smaller,  and  less  frequent,  and  the  latter  clearing;  if  the  urine 
should  lose  its  intensity  of  colour,  and  should  deposit  freely ;  if 
pain  abate  in  severity,  and  increase  in  constancy,  we  may  con- 
clude that  convalescence  is  about  to  take  place  sooner  or  later. 
We  say  sooner  or  later — for  there  is  no  disease  which  leaves  the 
system  with  so  much  reluctance  or  in  so  uncertain  a  condition  as 
regards  recovery,  as  rheumatism. 

3391.  For  though  the  favourable  signs  just  enumerated  may 
take  place,  there  is  no  security  they  will   continue;    for   the 
slightest  exposure,  errors  in  diet,  or  without  any  appreciable 
cause,  the  whole  of  the  distressing  symptoms  may  return  in  a 
moment,  and  involve  the  patient  anew  in  serious  disaster.     Or 
he  may  have  for  a  great  length  of  time,  transient  pain ;  or  per- 
manent stiffness  to  contend  with. 

3392.  This  disease,  notwithstanding  its  painful  severity,  is 
rarely  fatal ;  we  have  never  witnessed  a  single  instance  of  death 
when  it  preserved  its  original  locations,  though  we  have  seen 
much  danger  from  its  metastasis  to  some  important  part,  and 
once  death,  when  it  flew  to  the  heart.  And  within  a  few  days  we 
saw  it  attack  this  part  so  suddenly  and  violently,  as  to  threaten 
immediate  death ;  respiration  was  nearly  suspended,  and  the  ac- 
tion of  the  heart  so  impeded,  as  to  cause  the  most  serious,  and 
justifiable  alarm. 

Predisposing  Causes. 

3393.  Many  causes  have  been  enumerated  as  giving  disposi- 
tion to  rheumatism  ;  as  hereditary  conformation ;  constitution ; 
temperament ;  age  ;  habits  of  life ;  profession,  &c.  &c.   It  is  diffi- 
cult however  to  understand  how  some  of  these  causes  contribute 
to  this  end;  while  others  would  appear  to  be  sufficiently  obvious; 
for  instance,  of  hereditary  conformation,  as  a  predisposing  cause, 
we  can  know  but  little;  for,  as  Dr.  Scudamore  justly  observes,  from 


RHEUMATISM.  745 

it  "inferences  can  be  drawn  only  from  general  reasoning,  ob- 
servations, and  facts,  and  not  from  positive  demonstration,  there- 
fore we  cannot  pronounce  it  with  certainty  to  be  a  cause."  (p. 
35.)  While  it  appears  plain,  that  a  robust  and  vigorous  constitu- 
tion, and  certain  habits  of  life,  may  do  so;  for  the  first  seems 
naturally  to  dispose  the  system  to  take  on  inflammation  from 
the  application  of  almost  any  exciting  cause  ;  and  it  seems  equally 
plain,  that  the  same  disposition  may  be  artificially  created  by 
the  second.  And  though  we  do  not  exactly  understand,  why 
youth  on  the  one  hand  shall  to  a  certain  extent  give  an  immunity 
to  this  disease;  or  that  age  on  the  other  shall  increase  the  lia- 
bility ;  yet  we  are  obliged  to  acknowledge  it  to  be  a  fact,  if  any 
reliance  can  be  placed  upon  the  observations  of  writers  upon  this 
subject. 

3394.  Thus,   Chomel  says,  that  of  seventy-three  patients  in 
"PHopital  de  la  Charit6,"  affected  with  rheumatism,  thirty-five 
were  from  fifteen  to  thirty  years  of  age ;  twenty-two  from  thirty 
to  forty  ;  seven  from  forty-five  to  sixty ;  seven  were  above  sixty ; 
only  two  before  fifteen,  to  wit,  one  of  eight,  and  the  other  of 
nine.     Bichat  attempts  to  account  for  this,  by  saying,  in  early 
age  the  fibrous  system  is  soft,  while  in  old  people  it  becomes 
more  and  more  dense.  Dr.  Heberden  says,  "the  rheumatism  has 
appeared  as  early  as  in  a  child  only  four  years  old,  and  I  have 
seen  several  afflicted  with  it  at  the  age  of  nine  years."*     And 
Dr.  Davis,  in  his  dispensary  report,  says,  that  "at  the  end  of 
March,  and  in  the  beginning  of  April,  several  cases  of  acute 
rheumatism  were  admitted,  in  children  of  three,  four,  five,  six, 
and  seven  years  of  age,  and  upwards,  "t 

3395.  Dr.  Scudamore  thinks,  that  predisposition  "to  acute 
rheumatism,  is  from  fifteen  to  thirty;  and  to  chronic,  from  thirty 
to  sixty" — but  this  certainly  has  many  exceptions.   And  he  also 
observes,  "  that  whatever  causes  induce  debility,  either  generally 
or  partially,  predispose  the  body  to  rheumatism. "    He  also  enu- 
merates local  injuries,  as  dislocations,  strains,  or  contusions;  an 
unhealthy  state  of  the  digestive  organs,  sex,  season  of  the  year,  &c. 

Exciting  Causes. 

3396.  The  same  author  insists  that,  "  variable  temperature, 
experienced  either  generally  or  partially,  is  the  only  exciting 
cause  of  rheumatism  ;"  and,  that  "this  happens  through  the  me- 
dium of  moisture,  or  of  cold  air  alone;  or  more  especially  of  both 
conjoined,  operating  upon  the  whole  body,  or  in  part,  according 
to  the  particular  susceptibility  of  the  patient;  and  according  to 

•  Commentaries,  p.  400.  f  Medico-Chirurg.  Rev.  Oct.  1827. 

94 


746  liHEUMATISM. 

circumstances  of  exposure,  and  insufficient  protection  in  clothing. 
In  common  language,  we  use  the  term  cold ;  but  this  is  of  rela- 
tive signification  ;  and  the  cause  of  injury  consists  rather  in  the 
influence  of  variable  temperature,  than  of  absolute  cold  upon  the 
body  when  wholly  in  a  state  of  relaxation.  For  example,  expo- 
sure to  the  night  air  after  much  perspiration  from  dancing;  a 
stream  of  cold  air  upon  some  part  of  the  body  when  placed  in  a 
hot'  room,  especially  if  the  skin  be  relaxed ;  for  in  connexion 
with  this  state  of  the  surface,  the  several  textures  beneath  are 
more  readily  disturbed  in  their  functions;  and  we  may  reasona- 
bly argue  that  rheumatism  is  produced,  not  from  the  mere  sup- 
pression of  perspiration,  but  from  the  disturbance  in  the  economy 
of  the  cutaneous  circulation,  which  is  quickly  communicated  to 
the  fibrous  textures,  or  synovial  membranes,  or  nerves.  Any 
check  (reduction?)  to  the  temperature  of  the  skin,  so  permanent, 
that  healthy  reaction  does  not  take  place,  may  be  considered  as 
an  application  of  cold,  calculated  to  excite  rheumatism."  p. 
43,  &c. 

3397.  In  nothing  relative  to  disease,  is  the  opinion  of  medical 
men  more  concurrent  than  that  cold  in  some  form  or  other,  is 
the  exciting  cause  of  rheumatism,  and  it  is  now  also  pretty  ge- 
nerally agreed,  that  it  is  the  fibrous  tissues  that  become  the  seat 
of  this  affection.     The  fibrous  tissues  comprehend  the  articular 
capsules,  or  synovial  membrane,  the  ligaments,  the  aponeuroses, 
the  sheaths  of  tendons,  the  tendons,  the  periosteum,  the  peri- 
cardium, the  dura  mater,  the  sclerotica,  &c.;  to  which  may  be 
added,  agreeably  to  Burdin,  (Diet,  des  Scien.  Med.  Vol.  48,  p. 
480,)  "  the  stomach,  the  intestines,  the  bladder,  and  the  uterus, 
each  of  which  shows  a  white  fibrous  tissue,  and  which  may  be- 
come secondarily  in  these  organs,  the  seat  of  rheumatism.'*'  The 
latter  organ,  namely,  the  uterus,  we  are  certain  becomes  very 
frequently  the  primary  seat  of  this  disease.     We  have  seen  it 
follow  abortion  in  a  number  of  instances  from  the  exposure  of 
the  feet  to  wet;  and  we  regard  dysmenorrhoea  as  a  periodical 
rheumatism,  affecting  the  uterus,  during  the  menstruous  secre- 
tion.    The  degree  of  cold,  or  its  greater  or  less  application,  may 
in  some  measure  determine  the  seat  of  this  affection — thus  the 
more  superficial  fibrous  tissues  may  be  the  ones  affected  by  mo- 
derate exposure,  while  a  longer  continued,  or  a  more  intense 
degree  of  it,  may  penetrate  further,  and  reach  the  same  kind  of 
tissues,  that  are  deeper  seated. 

Proximate  Cause. 

3398.  It  appears,  that  the  proxi mate  cause  of  rheumatism  is 
a  phlogosed  state  of  one  or  more  portions  of  fibrous  tissue ;  and 


RHEUMATISM. 


747 


that  "  when  many  of  the  ligaments  and  tendons  are  inflamed, 
high  constitutional  irritation  arises,  as  also  does  fever.  Next  in 
order,  the  tendons  excite  this  sympathy,  those,  namely,  that  are 
confined  in  sheaths ;  for  tendinous  fibre,  and  aponeurotic  expan- 
sion, may  be  inflamed  without  much  disturbance  of  the  constitu- 
tion; as  we  observe  in  the  most  painful  lumbago,  or  in  the  form 
of  complaint  commonly  called  stiff-neck.  Redness  of  the  surface 
appears  almost  exclusively  when  the  superficial  ligaments  and 
the  sheaths  of  the  tendons  are  affected.  Bursal  inflammation  is 
seldom  accompanied  with  discoloration  of  the  skin.  Pain  is  felt 
most  acutely  accordingly  as  the  parts  affected  are  deep-seated, 
and  abates  very  much  in  proportion  as  swelling  occurs."* 

Diagnosis. 

3399.  Rheumatism  can  only  be  confounded  with  gout;  yet, 
the  peculiarities  of  each  disease  are  so  obviously  marked  as  to 
render  discrimination  sufficiently  easy.  The  following  schedule 
of  the  diagnoses  of  these  diseases,  is  taken  from  the  "  Diet,  des 
Sciences  Med.  Vol.  48,  Art.  Rheumatism." 


Predisposing  Circumstances. 


RHEUMATISM. 


Youth  to  ripe  age,  either  sex,  san- 
guine temperament,  constitution  ro- 
bust, laborious  professions,  poverty. 
Not  evidently  hereditary,  predisposi- 
tion not  innate. 


Mature  and  old  age,  men,  nervous 
temperament,  constitution  irritable, 
opulence.  Commonly  hereditary,  pre- 
disposition innate. 


Exciting  Causes. 


Rapid  changes  from  heat  to  cold  mois- 
ture, perspiration  suddenly  suppress- 
ed, gross  living,  exertion,  compres- 
sion— all  agree,  that  the  sudden  ap- 
plication of  cold  is  the  direct  cause. 


Sedentary  habits,  perspiration  slowly, 
diminished,  nutritious  and  stimulating 
food,  abuse  of  ardent  liquors,  coffee? 
enervation  from  the  pleasures  and  pains 
of  the  mind — not  excited  by  cold. 


Seat. 


Fibrous  and  muscular  tissues;  the 
great  joints;  rather  superficial,  occupy- 
ing a  large  surface,  a  variety  of  places 
at  the  same  time.  Parotids  frequently 
affected.  The  first  attack,  its  seat  un- 
certain. 


Synovial  capsules,  or  at  least  the 
white  portions  of  the  articulations,  not 
sensibly  extending  to  the  muscles;  the 
small  articulations.  Deep-seated,  con- 
centrated, never  attacking  the  whole 
of  the  articulations,  and  successively. 
Parotids  never  affected.  First  attack 
generally  limited  to  the  big  toe. 


Invasion. 


Sudden,  without  disturbance  of  sto- 
mach, for  the  most  part. 


Preceded  by  perversion  and  disturb- 
ance of  the  digestive  powers;  diminish- 
ed or  augmented  appetite;  disturbed 
sleep;  loss  of  energy. 


Scudamore,  p.  55. 


748 


RHEUMATISM. 


Symptoms. 


Pains  in  different  parts  of  the  body, 
butespecially  the  joints,  and  especially 
when  acute;  pain  spreading,  dull,  and 
squeezing,  (comprimante, )  pain  and 
swelling  coming  on  together;  redness, 
if  any,  rather  pale.  Cessation  of  pain 
not  followed  by  complete  relief.  A 
moderate  power  to  translate  itself  to 
other  parts. 


Pains  chiefly  in  the  articulations  of 
the -great  toe,  returns  regular  or  irre- 
gular, the  appearance  or  non-appear- 
ance, at  the  fixed  periods,  or  the  pre- 
mature disappearance,  is  followed  by 
various  lesions  of  the  internal  organs, 
and  especially  the  stomach;  pain  prick- 
ing, shooting,  dragging;  swelling  suc- 
ceeding pain;  redness  deep,  resem- 
bling erysipelas.  Cessation  of  pain 
followed  by  great  relief;  great  dispo- 
sition to  metastasis. 


Duration. 


First  attack  often  very  long:  an  at- 
tack rarely  lasting  less  than  fpur  days. 


First  attack   not   long:    sometimes 
only  twenty-four  hours. 


Metastases. 


Seldom,  and  slow.  Rheumatism 
rarely  quitting  the  articulations  and 
muscles,  to  take  possession  of  an  in- 
ternal organ,  especially  when  it  is 
acute.* 


Frequent  and  sudden.  The  gout 
abandoning  its  common  seat,  to  fix 
upon  the  viscera,  especially  those  of 
digestion. 


A  second  attack  almost  always  takes 
place  a  few  years  after  the  first.  The 
returns  are  without  provocation;  they 
generally  increase  in  frequency,  du- 
ration, and  intensity.  They  are  often 
periodical.  Gout  is  never  epidemic. 


An  attack  happens  often,  without 
being  followed  by  a  second.  The  re- 
turns are  hardly  ever  spontaneous; 
they  are  commonly  provoked  by  new 
exposures  to  the  primitive  cause  of  the 
disease.  These  returns  are  at  uncer- 
tain intervals.  Rheumatism  is  some- 
times epidemic. 

Species. 

Acute  rheumatism — chronic  much  I      Common  gout — asthenic  much  more 
more  frequent.  |  rare. 

Prognostic. 


Radical  cures  sufficiently  frequent. 
Affections  produced  by  metastasis,  not 
very  dangerous. 


Radical  cure,  rare  and  difficult.  Me- 
tastasis to  the  internal  organs,  often 
fatal. 


•  Dr.  Scudamore  says,  "  it  is  in  a  remarkable  degree  the  disposition  of  rheu- 
matic inflammation  quickly  to  change  its  seat;  and  the  abatement  of  sufferings 
in  one  part,  does  but  prepare  the  way  for  other  parts  to  be  similarly  affected. 
This  transfer  of  the  svmptoms  takes  place  with  surprising  quickness;  and  with 
more  frequency  of  change  than  in  the  gout."  p.  22.  This  statement  has  a 
little  surprised  us,  as  it  is  certainly  not  agreeably  to  our  own  observations,  nor 
of  most  others  who  have  treated  of  this  subject.  That  rheumatism  is  disposed 
to  metastasis  we  have  admitted;  but  we  think  it  only  remarkable,  because, 
there  is  no  other  disease  but  gout,  that  is  so  strongly  marked  in  this  particu- 
lar, if  we  except  the  occasional  transfers  of  erysipelas.  It  may,  however,  be 
remarked,  that  this  disposition  to  change,  is  more  frequent  in  some  habits, 
than  in  others.  We  have  two  patients,  who  rarely  have  an  attack  of  rheuma- 
tism, without  experiencing  a  metastasis;  while  we  have  many  that  have  never 
experienced  it. 


RHEUMATISM.  749 

Appearances  after  Death. 


Gelatine  and  albumen  in  the  muscu- 
lar and  ligamentous  meshes. 


Swelling  of  the  articular  extremities; 
concretions  in  the  articulations. 


Prognostic  and  Metastasis, 

3400.  Rheumatism  is  rarely  fatal,  especially  when  it  con- 
tinues in  its  original  seat,  and  confines  itself  to  the  external 
parts  of  the  body.     When  this  disease  becomes  dangerous,  it  is 
by  its  change  of  place,  as  this  may  be  to  some  important  or  vi- 
tal part,  as  the  brain,  stomach,  or  heart ;  and  though  of  rare  oc- 
currence, it  nevertheless  occasionally  takes  place.     More  or  less 
danger  always  arises  from  the  change  of  place  of  the  rheumatic 
inflammation;  for  though  the  newly-occupied  place  may  not  be 
of  vital  importance,   there  is  no  certainty  that  it  will  remain 
there  ;  for  whenever  it  takes  on  this  erratic  disposition,  we  have 
no  security  against  subsequent  wanderings;  and  the  danger  will 
then  be  in  proportion  to  the  intensity  of  the  disease  before  it 
moved,  the  value  of  the  organ  it  may  visit,  and  the  degree  of 
injury  it  may  inflict  there. 

3401.  Metastasis  may  take  place  without  any  evident  cause  ; 
we  have  seen  this  happen  when  the  blame  could  not  attach  to 
any  known  circumstance.     At  other  times,  it  has  been  driven 
from  its  original  location,  by  the  sudden  application  of  cold  to 
the  body,  or  from  the  improper  use  of  topical  remedies,  for  it 
is  the  acute  rheumatism  that  is  most  liable  to  change  its  situa- 
tion, and  it  is  for  this  form,  that  cold,  and  repelling^  applications 
are  most  frequently  made. 

3402.  Parts  that  are  debilitated,  or  over-excited,  are  the  most 
certain  to  incur  the  shock  of  metastasis.  -  Villenetfve  says,  that 
the  brain  has  become  (he  seat  of  invasion  after  the  use  of  opium. 
A  knowledge,  therefore,  of  this  disposition  to  change  seats  in 
rheumatism,  and  our  entire  inability  to  foresee  when  this  may 
take  place,  should  always  make  us  careful  of  our  prognosis,  in 
severe,  and  especially,  in  unsettled  cases. 

3403.  Dr.  Scudamore  says,  "  in  ordinary  cases,  therefore,  of 
rheumatism,  our  prognosis  relates  to  the  duration  of  the  disor- 
der, and  probably  there  is  no  disease  in  which,  as  to  this  point, 
we  can  give  a  less  certain  opinion.     The  favourable  circum- 
stances are,  early  relief  from  the  active  treatment  which  may 
have  been  employed ;  the  inflammation  keeping  its  station  very 
much  in  the  parts  first  attacked  ;  absence  of  delirium,  and  the 
constitutional  irritation  not  intense ;  perspiration  being  general 
and  moderate,  and  giving  relief,  instead  of  being  partial,  profuse, 
offensively  acid,  and  seeming  merely  to  occasion  exhaustion;  the 
pulse  keeping  within  the  range  of  100  or  110  in  the  minute,  and 


750  RHEUMATISM. 

being  free  from  hardness;  the  tongue  not  very  foul;  the  stomach 
not  affected  with  urgent  sickness,  nor  the  bowels  with  painful  ir- 
ritation; the  urine  in  the  course  of  ten  or  fourteen  days,  losing 
its  deep  red  appearance,  depositing  at  the  bottom  of  the  vessel  a 
lateritious  sediment,  and  by  degrees  becoming  altogether  clear, 
the  alvine  discharges  in  the  course  of  the  same  time,  losing  their 
unnatural  foetor  and  dark  appearance." 

3404.  "  The  threatenings  of   a    protracted    disease,  will   be 
shown  in  the  reverse  of  this  picture ;  and  more  especially  when 
the  transfer  of  inflammation  and  pain  quickly  takes  place  from 
one  part  to  another,  again  and  again  visiting  the  same  parts,  and 
being  unmanageable  in  treatment."  pp.  65,  66. 

Of  the  Treatment  of  Acute  Rheumatism. 

3405.  Unless  some  peculiar  epidemical  constitution  of  the  air 
shall  have  imposed  a  character  upon  this  disease,  it  will  always 
be  found  to  be  inflammatory,  and  to  have  imparted  to  the  san- 
guiferous  system,  sooner  or  later,  a  high  degree  of  action  ;  hence 
the  full,  and  resisting  pulse,  that  is  always  observed,  until  sweat- 
ing takes  place  or  has  continued  some  time.    In  no  disease,  per- 
haps, is  the  antiphlogistic  plan,  more  distinctly  called  for,  than 
in  acute  rheumatism,  when  the  local  irritation  is  sufficient  to  call 
into  action  the  circulatory  system;  nor  in  none,  wherein  relief 
so  tardily  rewards  exertion.     To  what  this  may  be  owing,  is 
perhaps  difficult  to  point  out — yet  it  would  appear  to  depend, 
upon  the  nature  of  the  parts  involved  in  the  disease,  rather  than 
to  a  mistaken  plan  of  treatment. 

3406.  The  disease  obviously  consists  of  inflammation  of  the 
fibrous  tissues;  the  economy  and  anatomical  characters  of  which, 
demonstrate  how  little  they  are  under  the  controul  of  the  general 
circulation ;  requiring  great  abstractions  from  it,  before  they  can 
be  made  to  feel  the  effects  of  the  exhaustion;  and  hence,  the  little 
relief  that  is  afforded,  by  even  great  losses  of  blood,  when  com- 
pared with  these  operations  for  disease,  in  several  of  the  other 
structures  of  the  body. 

3407.  However  important  the  true  pathology  of  disease  may 
be  ultimately,  we  are  obliged  to  confess,  that  it  does  not  always 
and  immediately  provide  us  with  remedies,  that  are  either  cer- 
tain or  prompt  in  the  removal  of  them.     It  nevertheless  points 
out  the  class  of  remedial  means,  which  is  always  the  first  step 
towards  the  discovery  of  specific,  or  appropriate  agents ;  and 
after  these  are  suggested,  it  must  be  left  to  a  well-directed  ex- 
perience, to  determine  the  value  of  the  respective,  or  individual 
article,  or  articles,  that  may  exert  the  happiest  influence  over  the 
disease  for  which  they  were  prescribed.    For  it  is  not  enough  to 


RHEUMATISM.  751 

the  removal  of  disease,  that  we  become  acquainted  with  its  proxi- 
mate cause ;  for  every  tissue  appears  to  have  its  own  laws,  or 
modes  of  action  ;  and  when  these  are  deranged  so  much,  as  to  be- 
come disease,  it  will  Require,  some  specific  agent,  or  general 
power,  the  mode  of  action,  of  which  shall  be  in  opposition  to  that 
of  the  deranged  structure. 

3408.  Thus,  we  see  inflammations  of  the  various  textures,  or 
even  inflammations  from  various  causes,  removed  in  many  in- 
stances by  apparently  opposite  means;  for  stimulants  and  seda- 
tives, as  they  are  called,  exert  an  analogous  ultimate  influence, 
upon  parts  labouring  under  phlogosis — hence,  blood-letting  and 
bark ;  the  preparations  of  lead,  and  the  nitrate  of  silver ;  cold  wa- 
ter, and  the  spirit  of  turpentine,  are  found  in  their  turn  to  re- 
move it.  What  particular  advantage  is  to  proceed  from  the  exact 
knowledge  of  the  pathology  of  rheumatism,  remains  yet  to  be 
determined  ;  for  so  far,  none  has  followed,  if  we  except  the  broad 
general  acknowledgment,  that  it  is  an  inflammatory  disease — but 
none  has  resulted  from  the  concession,  that  the  fibrous  structures 
are  the  seat  of  it.     It  is  true,  it  has  perhaps  explained,  why  par- 
ticular organs  shall  become  the  seat  of  this  disease,  when  from 
certain  causes  it  changes  its  location ;  and  this  is  the  extent  of 
its  usefulness  up  to  the  present  moment.     But  do  not  let  us  de- 
spair of  obtaining  the  most  satisfactory  and  useful  practical  hints 
from  this  knowledge ;  for  the  laws  of  sympathy,  and  counterac- 
tion, are  still  but  imperfectly  developed;  and  though  at  this  mo- 
ment, we  may  be  unacquainted  with  the  speediest  and  most  cer- 
tain means  of  subduing  this  peculiar  inflammation,  we  are  never- 
theless possessed  of  general  remedial  agents,  that  contribute  with 
tolerable,  though  tardy  certainty,  to  relieve  it. 

3409.  The  constitutional  symptoms  of  acute  rheumatism,  de- 
clare it  to  be  an  active  inflammation;  pain,  swelling,  and  disco- 
loration, are  its  common  attendants — pathological  research,  has 
determined   its  seat  with  considerable  certainty  to  be,  in  the 
fibrous  tissues;  and  experience  has  shown  the  necessity  and 
eventual  value,  of  the  antiphlogistic  plan  of  treatment  above 
every  other  hitherto  proposed.     Yet  all  who  have  treated  this 
disease  by  this  plan,  are  forced  to  acknowledge,  that  it  is  slow 
in  its  operation,  as  well  as  uncertain  in  its  relief.  Now  whether 
this  want  of  success  in  combating  rheumatic  inflammation,  (for 
we  believe  it  is  entitled  to  this  distinction,)  is  owing  to  anatomi- 
cal arrangement,  and  therefore  perhaps  insuperable,  or  from  our 
not  having  yet  discovered  its  counter-agent,  remains  to  be  de- 
termined, and  consequently,  we  can  only  for  the  present,  use 
such  remedies  as  experience  seems  to  decide  to  be  the  best ;  and 
of  these  bleeding  both  general  and  local,  claims  our  first  at- 
tention. 


752  RHEUMATISM, 


Of  Bleeding. 

3410.  Bleeding,  to  be  successful  in  rheumatism,  must  neces- 
sarily be  governed  by  the  same  general  principles  as  regulates 
its  employment  in  other  cases.     And  to  render  it  efficient,  or  to 
prevent  it  from  becoming  hurtful,  the  name  of  the  disease  must 
in  part  be  lost  sight  of,  though  its  habits  are  to  be  kept  in  view, 
and  its  employment  always  determined  by  the  state  of  the  sys- 
tem— that  is,  by  the  force  of  arterial  action;  the  degree  of  relief ; 
the  intensity  of  pain ;  the  state  of  the  skin,  &c. 

3411.  When  the  arterial  system  is  highly  excited;  when  the 
pulse  is  tense,  or  even  very  full,  and  only  somewhat  resisting, 
we  should  employ  this  remedy  sufficiently  freely,  to  insure  a 
more  moderate  state  of  the  circulation,  and  a  reduction  of  the 
force  of  the  pulse.     But  in  doing  this,  let  it  be  remembered,  as 
Dr.  Scudamore  very  justly  observes,  that  "  it  may  be  laid  down 
as  a  principle,  that  as  relating  to  the  local  inflammatory  action 
merely,  that  it  is  not  an  agent  in  which  we  should  place  our  con- 
fidence ;  for  it  disappoints  our  expectation  of  relieving  the  pain 
of  the  disease,  unless  as  the  pain  and  local  inflammation  may  be 
connected  with  the  true  inflammatory  diathesis."  p.  69.    In  no- 
thing is  the  young,  or  inexperienced  practitioner,  more  certainly 
disappointed,  than  in  the  want  of  power  of  blood-letting,  over 
the  agonizing  pain  of  acute  rheumatism — for  on  it  he  had  placed 
much  reliance,  because  everything  seemed  to  demand  its  em- 
ployment, and  every  thing  to  promise  success. 

3412.  We  have  known  this  failure  of  blood-letting  to  procure 
relief,  to  engender  a  belief,  that  it  must  be  an  improper  remedy 
in  acute  rheumatism  ;  and  that  stimulants  were  alone  indicated. 
We  once  saw  death  nearly  ensue  from  this  error ;  and  the  patient 
had  to  compound  for  it,  by  the  loss  of  the  use  of  one  hand ;  as 
the  wrist,  and  the  joints  of  every  finger  of  that  hand  had  become 
anchylosed.     Let  it  therefore  not  be  imagined,  that  because  the 
abstraction  of  blood  does  not  produce  immediate  relief,  that  it  is 
not  the  proper,  and  even  an  important  remedy;  at  least,  let  it  be 
viewed  as  one  that  will  diminish  danger,  if  it  does  not  suddenly 
overcome  suffering. 

3413.  In  some  few  instances  we  have  seen  remarkable  relief 
afforded  by  this  remedy,  whenever  it  was  employed ;  and  when 
this  happens  it  should  be  resorted  to,  when  pain  becomes  aggra- 
vated, and  febrile  excitement  renewed,  be  this  several  times  in 
the  twenty-four  hours.  While  on  the  contrary,  we  should  with- 
hold the  lancet,  when  it  fails  to  mitigate  suffering,  or  to  diminish 
arterial  action — for  we  have  seen  this  happen  when  both  seemed 
to  call  unequivocally  for  the  use  of  the  lancet.    Indeed,  in  a  few 


RHEUMATISM.  753 

instances,  we  have  thought  that  this  remedy  seemed  to  increase 
the  rapidity  of  the  circulation,  without  perceptibly  diminishing 
the  force  of  the  pulse.  We  have  also  thought,  that  blood-letting 
was  constantly  less  successful,  where  profuse  sweating  was  accom- 
panied with  great  heat  of  skin ;  and  on  the  contrary,  that  it  was 
pretty  sure  to  afford  relief,  whenever  the  skin  was  hot  and  dry. 
In  some  few  constitutions,  blood-letting  seems  but  to  increase 
the  irritability  of  the  heart.* 

3414.  Though  we  do  not  employ  bleeding  expressly  to  miti- 
gate pain,  we  nevertheless  use  it,  that  other  remedies  may  effect 
this;  for  without  blood-letting,  in  most  instances,  where  the  ge- 
neral system  has  been  roused  into  sympathy,  it  is  the  only  re- 
medy that  can  pave  the  way  for  the  employment  of  opium.     In 
this  climate  it  may  be  well  to  observe,  blood-letting  can  be  used 
to  a  greater  extent,  than  in  most  of  the  European  countries;  and 
therefore,  the  apprehensions  expressed  by  many  of  the  writers 
of  those  countries,   namely,  that  blood-letting  is  of  doubtful 
efficacy  to  say  the  least,  will  not  apply  to  this  disease,  in  this 
country. 

3415.  On  this  account,  we  cannot  agree  with  Dr.  Scudamore, 
that  even  extensive  blood-letting  necessarily  induces  a  chronic 
form  of  this  disease,  though  a  chronic  form  may  follow  its  em- 
ployment; for  before  we  admit  this,  it  would  be  well  to  ask, 
what  the  situation  of  the  patient  might  be,  were  it  not  liberally 
employed — a  condition  we  are  disposed  to  believe,  even  worse 
than  chronic  rheumatism.  Therefore,  in  such  cases,  we  believe, 
nay  we  may  say  we  are  sure,  that  the  chronic  form  was  not  in- 
duced by  the  bleedings;  but  that  the  bleedings  were  only  capa- 
ble of  reducing  the  inflammation  to  the  sub-acute  or  chronic 
form — if  this  be  so,  it  only  proves  the  inadequacy  of  the  remedy, 

*  "Now  if  we  mark  the  symptoms  and  progress  of  rheumatism  in  its  acute 
form,  we  may  observe  very  frequently  that  a  well-developed  febrile  action,  but 
without  any  symptom  that  would  denote  a  local  affection,  precedes  pain.  In- 
deed there  is  an  inflammatory  fever  first,  and  then  rheumatism.  We  may  also 
observe  the  erratic  tendency  of  the  rheumatic  pain;  they  run,  as  it  were,  in 
the  course  of  the  distribution  of  the  blood;  the  application  of  leeches  will  often 
remove  the  pain  from  one  part,  for  it  only  to  shift  to  another;  and  it  is  not  un- 
usual for  it  to  leave  the  articulating  tissues,  to  fix  upon  some  of  the  internal 
organs,  producing  derangements  of  greater  or  less  severity  in  their  functions. 
It  however  happens  sometimes,  that  a  bleeding  from  a  large  orifice  will  put  an 
end  to  the  disease;  as  if  the  diminution  of  the  mass  of  blood  proportionably 
lessened  the  stimulus  that  caused  these  shifting  irritations.  When  this  happens, 
the  buffy  coat  becomes  less  evident  in  the  subsequent  bleedings,  and  even- 
tually disappear.  But  on  the  contrary,  if  the  rheumatism  does  not  give  way  to 
blood-letting,  the  buffy  coat  continues,  and  even  becomes  more  evident,  as  we 
persist  in  repeating  the  venesections — the  serum  increases,  while  the  coagulum 
decreases;  and  be  the  coagulum  ever  so  small,  it  is  nevertheless  covered  with 
a  buffy  coat,  and  this  as  long  as  the  disease  continues." — Jlndral,  Path.  Anat, 
Vol.  I.  p.  667. 

95 


754  RHEUMATISM. 

and  not  its  hurtful  quality.  That  it  is  unavailing  sometimes,  as 
\ve  have  stated  above,  we  are  free  to  admit — but  these  are  per- 
haps but  exceptions  to  the  general  rule.  We  think  it  therefore 
on  every  account  the  safest  plan,  to  draw  blood  from  the  arm, 
so  long  as  intense  suffering,  and  an  active  pulse  call  for  it;  for  if 
we  should  fail  to  subdue  inflammation  by  it,  and  thereby  fail  to 
diminish  pain,  we  nevertheless  so  far  reduce  arterial  action,  as  to 
make  the  employment  of  narcotics,  or  sudorifics,  if  called  for  by 
the  state  of  the  skin,  available. 

3416.  But  a  period  almost  constantly  arrives  in  acute  rheu- 
matism, if  proper  depletion  has  been  premised,  where  local 
bleeding  may  be  put  in  requisition  with  much  advantage;  but 
this  period  must  be  permitted  to  arrive  before  it  be  resorted  to, 
if  we  would  expect  the  full  benefit  of  this  mode  of  abstracting 
blood.     For  there  is  truly  a  local  bleeding  point,  as  well  as  a 
blistering,  or  a  sweating  point;  which  if  not  observed,  will  very 
much  diminish  the  efficacy,  if  not  altogether  destroy  the  useful- 
ness of  it.  Therefore,  that  leeching  or  cupping  may  be  auxiliary 
to  general  bleeding,  the  force  of  arterial  action  must  first  have 
been  abated  by  the  latter. 

3417.  We  may  then  with  much  advantage  have  recourse  to 
local  bleeding,  if  pain,  tenderness,  and  redness  continue,  pro- 
vided the  force  of  arterial  action  is  sufficiently  abated  to  render 
it  available.  For  it  is  a  fact,  sufficiently  well  established  to  justify 
the  declaration,  that  neither  leeching  nor  cupping  are  in  the 
slightest  degree  useful,  so  long  as  the  pulse  is  very  active  and 
tense.  Why  this  is  so,  it  may  be  difficult  to  explain.   May  it  not 
be,  because  the  capillaries  remain  engorged,  so  long  as  the  larger 
vessels  continue  to  be  filled?  and  that  they  will  only  yield  their 
contents  when  these  vessels  make  a  demand  upon  them,  from, 
becoming  comparatively  empty? 

3418.  Be  this  as  it  may,  the  fact  is  certain,  that  no  advantage 
is  derived  from  leeching  or  cupping,  until  after  the  arterial  tone 
is  diminished.     Nay,  we  think  we  have  seen  it  mischievous 
sometimes,  but  certainly  unprofitable,  until  after  this  time.     If 
circumstances  then  require  the  further  abstraction  of  blood,  and 
it  does  not  appear,  that  advantage  can  be  gained,  or  that  it  would 
be  imprudent  to  abstract  it  from  the  arm,  we  may  resort  to  topi- 
cal depletion ;  regulating  the  quantity  to  be  abstracted   by  the 
exigency  of  the  case.     It  is  usual  to  apply  the  leeches  upon  the 
part  affected ;  we  are  disposed,  however,  to  doubt  the  propriety 
of  this;  for  we  think  we  have  seen  more  certain  good  derived, 
when  they  have  been  placed  around  the  margin  of  the  pained 
part.    The  after-bleeding  of  these  animals  should  be  encouraged 
by  covering  the  wounds  with  cloths  wrung  out  of  hot  water ; 
and  they  may  be  repeated,  pro  re  nata. 


RHEUMATISM.  755 

3419.  The  same  may  be  said  nearly,  of  cupping;  the  cups 
should  be  applied  at  some  distance  from  the  pained  or  inflamed 
part,  unless  the  pain  be  deep  seated.     There  are  two  kinds  of 
cupping,  the  wet  and  the  dry.     The  first  is  where  the  scarifica- 
tor  is  employed  ;  and  the  second  where  it  is  not — -each  has  its 
advantages.   The  scarificator  and  cups  should  be  used,  whenever 
it  is  desirable  to  abstract  considerable  blood ;  that  is,  from  five 
ounces,  to  fifteen  or  twenty;  if  less  than  this,  be  wished,  and  it 
is  an  object  to  produce  irritation  without  a  great  expenditure  of 
blood,  the  dry  cupping  answers  admirably;  for  it  serves  the  dou- 
ble purpose  of  taking  so  much  blood  from  the  capillaries,  and  of 
producing  vesication;  for  dry  cupping  should  almost  always  be 
carried  to  this  extent ;  and  this  will  be  effected  by  the  cups  re- 
maining attached  for  about  three-quarters  of  an  hour.  It  requires 
for  the  most  part,  that  the  scarifications  should  be  crossed  by  the 
instrument,  when  a  considerable  quantity  of  blood  is  wanted ; 
and  sometimes,  when  the  cups  are  applied  to  parts  that  do  not 
yield  much  blood ;  as  the  lower  part  of  the  back  and  abdomen. 

3420.  As  regards  the  choice  of  leeching,  or  cupping,  much 
will  depend  upon  the  part  affected,  and  the  age  of  the  patient — 
leeching,  generally  is  best,  near  the  smaller  joints,  and  head,  es- 
pecially in  young  subjects;  while  cupping  answers  better  near 
the  larger  joints,  to  the  chest,  between  the  shoulders,  the  back, 
and  when  the  pain  is  deep  seated. 

3421.  As  much  of  our  success  in  the  treatment  of  rheuma- 
tism will  depend  upon  the  reduction  of  inflammation  ;  and  as  this 
will  very  much  depend  upon  the  proper  use  of  remedies,  and 
especially,  blood-letting,  it  becomes  important  that  we  do  not 
withhold  the  lancet  too  early,  or  employ  it  unnecessarily.     Ex- 
perience has  constantly  shown,  that  the  pulse,  as  regards  its  ac- 
tivity, or  volume,  does  not  always  call  for  the  further  abstrac- 
tion of  blood  from  the  arm — we  have  already  said,  that  this,  in 
certain  cases,  was  not  only  unavailing,  but  injurious;  therefore, 
it  will  require  nice  observation  in  some  instances  to  determine 
where  it  must  be  employed,  or  when  it  must  be  suspended.  We 
have  in  another  place  laid  down  Laennec's  rules  upon  this  sub- 
ject, and  to  which  we  now  refer,  (see  par.  1563,)  remarking, 
however,  in  addition,  that  blood-letting  is  never  advantageously 
carried  to  the  same  extent  in  rheumatism,  as  is  found  necessary 
sometimes  in  pneumonia,  pleurisy,  or  in  dysentery.     Yet  we 
think  it  proper  to  refer  to  Laennec's  discrimination,  lest  the 
pulse  betray  us  into  error  on  this  point. 

3432.  We  should  also  guard  against  being  led  into  mistake, 
from  the  appearances  of  the  buffy  coat  upon  the  blood.  This  led 
Sydenham  astray  at  first,  but  he  subsequently  corrected  the  error. 
And,  though  we  strongly  advocate  the  loss  of  blood  in  acute 


756  RHEUMATISM. 

rheumatism,  and  especially  in  robust  and  plethoric  habits  to  a 
certain,  and-  occasionally  even  to  a  considerable  extent,  we  never 
should  call  the  attention  to  the  appearance  of  "  size,"  as  ajustifi- 
cation  for  its  repetition;  for  we  know  from  experience,  that  this 
form,  or  state  of  blood,  will  continue  sometimes  far  beyond  the 
period  at  which  it  would  be  proper  to  abstract  more.  The  young 
practitioner  must  therefore  be  upon  his  guard,  not  to  fall  into 
the  error  of  those  who  have  made  this  circumstance  their  guide. 
And  in  acute  rheumatism,  as  in  every  other  active  disease,  at- 
tention should  be  paid  to  the  age,  constitution,  epidemical  in- 
fluence, and  location  of  the  patient.  See  note  par.  3413. 

Purging. 

3423.  Purging,  however  useful,  is  not  always  eligible  in  rheu- 
matism ;  not  because  it  is  not  always  an  important  auxiliary  to 
bleeding,  but  because  the  extreme  helplessness  of  the  patient 
sometimes  renders  it  very  inconvenient  and  painful ;  and  for 
these  reasons  cannot  always  be  employed  with  advantage.     But 
when  this  objection  does  not  obtain,  purgatives  should  be  re- 
sorted to  almost  daily;  or  until  the  more  violent  symptoms  have 
suffered  abatement. 

3424.  For  this  purpose  we  almost  always  begin  with  a  few 
grains  of  calomel,  purging  it  off  with  neutral  salts  alone,  or  com- 
bined with  magnesia.     Say,  for  an  adult,  ten  or  twelve  grains 
of  calomel,  and  proportionably  less  for  young  subjects;  giving 
after  it,  at  the  end  of  two  hours,  the  above-named  medicines  in 
divided  doses  until  they  produce  ample  catharsis.     We   have 
also  given  with  much  advantage  a  solution  of  the  sulphate  of 
magnesia,  or  Epsom  salt,  in  lemonade,  with  a  small  quantity  of 
the  tartrite  of  antimony.* 

3425.  Dr.  Scudamore  says  he  has  "  been  much  pleased  with 
the  effects  of  a  draught  composed  of  the  carbonate  of  magnesia, 
carbonate  of  potash,  sulphate  of  magnesia  in  small  doses,  tarta- 
rized  antimony,  lemon  juice  in  fit  proportion  to  neutralize  the 
carbonate  of  potash,  and  the  acetum  colchici,  with  some  agree- 
able distilled  water  and  syrup.     The  draught  may  be  taken  in 
effervescence  or  otherwise.     The  addition  of  the  tartar  emetic 
is  exceedingly  valuable;  for  my  increasing  experience  with  this 
medicine  convinces  me,  that  it  is  one  of  the  most  useful  reme- 
dies which  we  can  employ  for  the  removal  of  inflammatory  ac- 
tion ;  and  in  proportion  as  we  use  it  with  judgment,  so  do  we 

*  Take  1  ounce  of  Epsom  salt, 
1  grain  of  tartar  emetic, 

Dissolve  in  eight  ounces,  or  half  a  pint,  of  hot  lemonade — when  cool,  give  a 
table-spoonful  every  half  hour,  until  it  operate  freely. 


KHEUMATISM.  757 

diminish  the  necessity  of  using  the  lancet."  p.  92.  "  Upon  the 
first  administration  of  the  tartar  emetic,  it  usually  sickens  to  the 
degree  of  causing  vomiting;  but  this  effect  is  useful,  and  it  is 
surprising  how  quickly  the  stomach  accommodates  itself  to  this 
medicine.  The  maximum  and  minimum  doses  of  tartar  emetic, 
which  I  usually  employ  in  the  combination  just  spoken  of,  are 
one  grain,  and  one-eighth  of  a  grain;  and  of  the  acetum  colchici, 
a  drachm  and  a  half,  and  half  a  drachm. "  p.  93. 

3426.  If  we  have  reason  to  suspect  any  hepatic  derangement; 
or  if  the  al vine  evacuations  are  bilious,  the  calomel  should  be 
repeated,  from  time  to  time,  so  long  as  these  conditions  may  re- 
quire it.   When  these  causes  for  the  exhibition  of  calomel  exist, 
we  believe  it  would  be  vain  to  attempt  their  relief  by  any  other 
medicine;  and  we  entirely  agree  with  Dr.  Scudamore,  that  this 
plan  should  be  continued  until  the  stools  assume  a  natural  ap- 
pearance; after  this  the  more  gentle  purgatives  may  be  substi- 
tuted. 

Diuretics. 

3427.  It  has  always  been  found  useful  to  encourage  the  dis- 
charges from  the  kidneys;  this  is  sometimes  well  promoted  by 
the  purgatives ;  but  we  have  found  nitre  in  form  of  the  antimo- 
nial  powders,  with  or  without  the  calomel,  as  may  be  judged 
best,  (see  par.  342,)  highly  useful  in  the  more  active  stage  of 
this  complaint;  and  when  this  is  abated,  the  vinous  tincture 
of  the  seeds  of  colchicum  in  thirty  or  forty  drop  doses  every 
four  hours,  answer  exceedingly  well.   But  the  first  of  these  me- 
dicines need  not  be  continued  after  the  urine  becomes  sufficiently 
abundant,  and  deposits  a  lateritious  sediment;  though  its  further 
employment  may  be  useful  towards  the  reduction  of  inflam- 
matory action,  if  the  stomach  do  not  revolt.     The  tincture  of 
colchicum  may  be  persevered  in  as  it  exerts  an  influence  over 
the  rheumatic  action  beyond  any  medicine  with  which  we  are 
acquainted. 

Sudorifics. 

3428.  It  becomes  rarely  necessary  in  acute  rheumatism  to 
employ  this  class  of  remedies;  for  we  have  remarked  above, 
that  a  dripping  skin  is  no  uncommon  attendant  upon  this  dis- 
ease; but  at  the  same  time  it  affords  less  relief  than  any  other 
evacuation.     Yet  it  occasionally  happens,  that  this  state  of  the 
skin  does  not  take  place  when  it  might  be  useful;  or,  that  it  has 
been  checked  by  some  means  or  other,  to  the  aggravation  of  the 
existing  symptoms;  in  this  case,  minute  doses  of  the  tartrite  of 


758  RHEUMATISM. 

antimony,  in  the  neutral  mixture,  will  answer  exceedingly  well. 
For  this  mixture  see  par.  342. 

Of  Opium. 

3429.  An  anxiety  to  relieve  pain,  very  often  leads  to  the  too 
early  use  of  opium  in  this  disease.     In  some  instances  this  pro- 
duces an  evident  aggravation  of  every  symptom,  while  in  others 
it  causes  very  serious  mischief.     Opium,  like  blisters,  is  very 
rarely  neutral  in  its  effects — it  either  does  good  or  harm  ;   great 
caution  is  therefore  required  in  its  administration.     We  have  in 
many  places  inculcated  the  necessity  of  attending  to  the  state  of 
the  system,  before  it  is  given,  and  in  rheumatism  this  must  not 
be  lost  sight  of;  it  requires  a  well-subdued  pulse ;  a  freedom  from 
particular  determination  to  the  head ;  a  moist  skin  and  tongue  ; 
open  bowels;  and  a  certainty  that  it  does  not  from  idiosyncrasy 
constantly  disagree  with  the  patient,  before  it  can  be  exhibited 
with  advantage. 

3430.  In  some  instances,  and  these  are  not  very  unfrequent, 
it  is  found,  that  opium  in  the  ordinary  forms  will  disagree  with 
the  patient — when  this  happens,  it  is  always  unfortunate  for  the 
patient,  as  he  is  deprived  of  the  important  aid  of  this  valuable 
drug.      Common  laudanum  must  not  however  establish  the  rule 
upon  this  point,  as  it  will  very  often  disagree,  while  other  forms 
of  opium  may  be  given  without  inconvenience;  thus  the  black 
drop,  the  denarcotized  laudanum  or  opium ;  the  acetate  or  sul- 
phate of  morphia,  or  morphia,  may  be  used,  when  the  common 
opium  or  laudanum  cannot.     On  this  account,  it  is  proper  to 
yield  to  the  humour  of  the  idiosyncrasy,  rather  than  attempt  to 
force  it.     Thus  we  may  give  fifteen  drops  of  the  black  drop, 
thirty  of  the  denarcotized  laudanum,  or  a  grain  of  the  denarco- 
tized opium,  or  the  sixth  of  a  grain  of  morphia,  or  its  acetate  or 
sulphate,  with  great  advantage,  when  the  patient  cannot  take  the 
common  preparations. 

3431.  When  opium  is  admissible  in  rheumatism,  we  generally 
exhibit  it  at  bed-time,  in  the  form  of  Dover's  powder,  (see  par. 
244,)  provided  the  skin  be  not  dripping — if  the  skin  be  too  moist, 
we  have  often  found  much  advantage  in  combining  it  with  col- 
chicum.*     Dr.  Scudamore  recommends  its  use  in  the  day  when 
*  R.  Tinct.  vin.  sem. 


colchici  gt.  xxx.  vel  xl. 

Thebaic.  denar- 

cot.  gt.  xxv.  vel  xxx. 

Sacch.  alb.         Zsa. 
Aq.  font.  3j. 

M. 
To  be  taken  at  bed-time. 


Take  Vinous  tincture  of 

colchicum  seeds  30  to  40  drops. 
Denarcotized  lau- 
danum 25  or  30  drops. 
White  sugar  £  drachm. 
Common  water       1  ounce. 
Mix. 


RHEUMATISM. 


759 


pain  is  severe.  He  says,  "  if  all  the  indications  of  treatment 
are  correctly  fulfilled,  we  may  also,  with  every  propriety  direct 
an  opiate  dose  during  the  day,  when  pain  is  urgent."  For  this 
purpose,  he  recommends  the  opium  to  be  combined  with  a  neu- 
tral mixture  and  camphor,*  which  may  perhaps  exalt  its  vir- 
tues. When  opium  disagrees  in  every  form,  it  is  sad  for  the 
patient;  especially  where  pain  continues  after  the  inflammatory 
symptoms  have  disappeared.  In  such  cases,  we  have  to  rely 
chiefly  upon  the  colchicum ;  Dr.  Scudamore  combines  it  with 
the  camphorated  mixture,  and  gives  it  every  six  or  eight  hours — 
we  are  in  the  habit  of  giving  it  every  three  hours  without  the 
camphor. 

3432.  Opiates  are  given  in  enemata  sometimes,  with  great  ad- 
vantage ;  and  by  these  means,  the  unpleasant  effects  experienced 
by  their  exhibition  by  the  mouth,  are  sometimes  entirely  obvi- 
ated— when  laudanum  is  exhibited  in  the  form  of  an  enema,  we 
must  treble  the  ordinary  dose ;  it  should  be  mixed  in  two  or  three 
ounces  of  lukewarm  water.      Should   the  peculiarities  named 
above  exist,  it  will  be  well  to  try  the  other  forms  of  opium,  as 
recommended  above,  when  it  was  to  be  taken  into  the  stomach. 
It  is  almost  unnecessary  to  repeat,  that  during  the  whole  course 
of  treatment,  a  strict  antiphlogistic  regimen  must  be  observed. 

Local  Applications. 

3433.  Much  serious  mischief  is  oftentimes  done,  by  ill-timed 
local  applications.     We  can  scarcely  be  too  severe  in  our  repre- 
hensions of  stimulating  embrocations,  liniments,  and  plasters, 
that  are  so  frequently  resorted  to  in  acute  rheumatism;  they 
should  one  and  all   be  proscribed  as  worse  than   useless.     We 
know  of  but  one  application  in  this  complaint,  that  is  decidedly 
successful  in  abating  pain,  and  from  which  no  evil  so  far,  has 
followed  its  employment — this  is  warm  sweet  oil.    The  affected 


*R.Potassje  carbon.         gr.  cviij. 
Sue.  citric,  (recentis)  (fij. 
Mist,  camphorae          ^iijss. 
Liquoris  opii  sedativ.  Ziss.  ad  gij. 
Syrupi  tolutan.  ,^ss. 

Antim.  tartarisat.       gr.j.adgr.ij. 
M.  fiat  mistura. 


Take  Carbonate  of 

potash         108  grains. 
Fresh  lemon 

juice  2  ounces. 

Camphorated 

mixture        3J  ounces. 
Sedative  liquor 

of  opium      1£  to  2  drachms. 
Syrup  of  tolu     \  ounce. 
Tartar  emetic    1  to  2  grains. 

Mix. 

"  Of  this  mixture,  one,  two,  or  three  table-spoonfuls  should  first  be  taken,  ac- 
cording to  the  degree  of  pain;  and  a  dose  should  be  repeated  every  hour  or 
two,  fill  relief  is  obtained." 


760  RHEUMATISM. 

part  must  be  bathed,  (not  rubbed,)  with  it  frequently  if  pain  con- 
tinue; and  it  is  oftentimes  truly  surprising  to  see  with  what  sud- 
denness it  affords  relief. 

3434.  The  following  cases  of  benefit,  from  the  local  applica- 
tion of  morphia,  deserve  attention,  as  they  seem  to  point  out  an 
important  and  apparently  a  certain  means  of  relief  from  local 
applications,  after  the  system  has  been  lowered  by  previous  de- 
pletion. 

3435.  Case  I. — "A  woman,  aged  twenty:eight,  had  a  smart 
attack  of  rheumatism  in  both  knees^  the  shoulders,  and  wrists; 
the  pains  were  very  constant,  and  the  affected  parts  were  con- 
siderably swollen  and  red.     She  was  freely  bled  from  the  arm, 
without  relief — blood  sizy.     A  blister  on  each  was  ordered,  and 
the  raw  surfaces  to  be  dressed  with  half  a  grain  of  the  acetate  of 
morphia ;  for  the  three  subsequent  days  she  was  quite  free  from 
pain — the  quantity  of  morphia  increased  to  three-quarters  of  a 
grain.     In  two  days  more  she  had  completely  recovered." 

3436.  Case  II. — "A  man,  aged  twenty-seven,  was  seized 
with  violent  pains  in  both  knees  on  the  15th  of  March.     On  the 
22d,  the  joints  were  blistered,  and  a  quarter  of  a  grain  of  mor- 
phia was  applied.     In  two  days  the  pains  were  much  relieved. 
On  the  28th,  he  was  pronounced  cured." 

3437.  Case  III. — "  A  young  man,  aged  sixteen,  suffered  un- 
remitting pains  in  the  knees,  wrists,  and  elbow-joints,  which 
were  swollen,  red,  and  very  tender  on  pressure,  and  incapable 
of  being  moved.     For  three  nights  he  could  not  sleep  from  the 
severe  suffering;  pulse  full,  skin  burning  hot;  he  was  bled  and 
starved.     Next  day  the  pulse  was  more  favourable,  but  the  pain 
rather  worse.     A  blister  to  be  applied  to  each  knee,  and  the  sur- 
faces to  be  dressed  with  a  quarter  of  a  grain  of  the  acetate  of 
morphia.     This  treatment  was  continued  for  four  days,  when 
the  patient  made  no  complaints  but  from  the  blistered  surfaces." — 
Med.   Chirur.  Rev.  for  Oct.   1832,  from  Jour.    Univer.   et 
Hebdom. 

3438.  Another  error  is  very  often  committed  by  local  means — 
namely,  keeping  the  part  too  warmly  covered ;  flannel,  and  other 
woollen  substances  are  made  to  surround  the  part,  with  a  view 
it  is  said  of  producing  perspiration.     All  such  applications  must 
be  prohibited  in  acute  rheumatism ;  as  they  only  torment  the 
patient  by  increasing  the  heat  of  the  part,  which  should  at  most, 
be  lightly  covered ;  and  when  it  is  very  hot  it  should  be  exposed 
to  the  air. 

3439.  We  have  seen  however  much  relief  from  the  applica- 
tion of  carded  wool,  when  all  fever  has  been  removed,  but  pain 
still  remaining.     Flakes  of  carded  wool  must  be  made  to  cover 
the  afflicted  part,  and  kept  in  their  place  by  surrounding  tnem 


RHEUMATISM.  761 

with  the  oiled  silk,  (like  that  used  for  hat  covers,)  and  this  se- 
cured by  properly  adjusted  bandages.  If  this  application  act 
kindly,  the  covered  portion  will  be  excited  to  even  profuse  per- 
spiration ;  but  if  this  do  not  take  place  in  half  an  hour,  it  will 
not  succeed  by  giving  it  more  time — in  this  case,  it  should  be 
removed.  But  if  on  the  contrary,  perspiration  ensue,  much  re- 
lief will  be  experienced,  and  the  wool  soon  becomes  saturated 
with  moisture.  When  this  happens,  the  wool  must  be  changed, 
and  its  place  supplied  by  a  fresh  application  of  it — it  will  there- 
fore require  two  dressings  of  this  article  to  be  at  hand.  The 
wool  that  has  been  removed  must  be  dried  before  the  fire,  and 
carded  anew  when  it  becomes  matted. 

3440.  We  never  employ  blisters  in  acute  rheumatism;  at  least 
'while  the  disease  maintains  its  first  position — if  a  new  part  be 

occupied  by  metastasis,  we  are  sometimes  under  the  necessity 
of  using  them,  either  to  the  part  departed  from,  or  to  the  new 
location.  We  have  already  remarked  upon  the  disposition  this 
disease  occasionally  has  to  shift  its  ground;  and  when  this  happens 
to  some  internal  organ,  it  is  almost  always  fatal.  One  of  its  most 
frequent  seats  when  it  makes  this  change,  is  the  heart,  and  pro- 
duces pericarditis,  which  see.  Dr.  David  Pitcairn,  in  1788, 
agreeably  to  Dr.  Wells,  was  the  first  to  notice  the  connexion 
between  the  organic  lesions  of  the  heart  and  rheumatism ;  his 
observations  have  since  been  amply  confirmed  by  a  number  of 
observers,  and  are  now  generally  acknowledged — at  least,  that 
acute  rheumatism  and  pericarditis  have  very  frequently  a  com- 
mon cause.  Dr.  Scudamore  has  selected  a  number  of  interesting 
cases,  to  which  we  refer ;  as  also  to  Dr.  Johnson's  work  on  the 
Influence  of  the  Atmosphere,  &c. 

Sub-acute  or  Chronic  Rheumatism. 

3441.  Dr.  Scudamore  is  of  opinion,  that  a  state  "intermediate 
between  acute  and  chronic  rheumatism,"  is  frequently  met  with. 
He  says,  "  the  essential  character  of  sub-acute  rheumatism  is, 
that  its  attack  is  either  partial,  or  so  limited  in  degree,  that  the 
constitution  is  not  affected  with  much  sympathetic  fever;  and  it 
frequently  happens,  that,  notwithstanding  there  is  great  local 
suffering,  no  general  fever  is  present.  Either  bursa,  tendon,  apo- 
neurosis,  ligament,  or  nerve,  may  be  the  texture  affected,  and  we 
often  find  that  one  kind  of  texture  only  is  the  seat  of  the  disease 
at  the  same  time."  p.  161. 

3442.  Notwithstanding  the  opinions  of  this  highly  valuable 
practitioner  on  the  difference  between   sub-acute  and  chronic 
rheumatism,  we  cannot  find  it  necessary  or  proper  to  make  the 
distinction,  especially  as  no  practical  good  appears  to  be  derived 

96 


762  RHEUMATISM. 

from  it.  We  think  it  a  good  rule  to  refuse  distinctions  that'are 
not  justified  by  pathological  changes  in  the  involved  parts,  or 
that  do  not  require  a  difference  of  treatment ;  if  we  do,  it  is  al- 
most sure  to  confuse  the  young  practitioner,  and  lead  him  to 
an  uncertain  and  vacillating  treatment.  For  these  reasons,  vre 
would  merge  these  names,  and  call  the  affection  either  sub-acute, 
or  chronic — we,  however,  prefer  the  former,  as  it  in  some  de- 
gree leads  to  the  pathological  condition  of  the  disordered  part. 

3443.  The  sub-acute  rheumatism,  must  be  looked  upon  as  a 
minor  grade  of  the  acute — in  this  stale,  (the  sub-acute,)  the  sys- 
tem sympathizes  feebly,  or  not  at  all  with  the  affected  part,  be 
this  bursa,  tendon,  ligament,  aponeurosis,  &c.;  yet  there  exists 
inflammation,  agreeably  to  Dr.  Scudamore's  own  showing,  in 
whatever  part  may  have  become  the  seat  of  the  disease.   For  the 
only  possible  difference  that  we  can  perceive  in  these  varieties, 
(for  they  are  nothing  more,)  is  the  degree  of  inflammation ;  thus 
Dr.  S.  acknowledges,  that  as  regards  distinction  "between  the 
sub-acute  and  chronic,  the  limits  are  narrow;  and  in  many  in- 
stances, it  would  be  difficult  to  determine  which  of  these  terms 
would    be  most  descriptive   of  the   diseased   action."  p.    337. 
Again,  "  by  chronic  rheumatism,  I  intend  to  designate  that  form 
of  the  disease  which  is  wholly  unattended  by  constitutional  fe- 
ver, and  scarcely  marked  by  any  signs  of  local  inflammatory 
action ;  for  in  proportion  to  the  existence  of  such  signs,  the 
term  sub-acute  would  be  the  more  appropriate  appellation." 
p.  338. 

3444.  From  this  it  is  evident,  that  the  sub-acute,  and  chronic 
rheumatism,  are  but  one  and  the  same  affection ;  differing  but  in 
the  degree  of  local  inflammation ;  and  that  their  treatment  does 
not  vary  in  any  greater  degree  than  as  the  treatment  of  one  in- 
termittent or  a  pleurisy  may  differ  from  another;  and  it  is  the, 
tact,  which  experience,  and  well-disciplined  observation  gives, 
that  makes  one  practitioner  superior  to  another,  by  enabling  him, 
sur  le  champ,  to  accommodate  the  nature  and  force  of  his  reme- 
dies, to  the  state  of  the  disease.     One  intermittent,  or  a  pleurisy, 
may  require  twice  as  much  bark,  or  depletion,  as  another;  yet 
the  variation  in  the  mode  of  treatment,  does  not  change  the  na- 
ture of  the  diseases. 

3445.  For  these  reasons  we  can  only  acknowledge,  the  acute, 
and  the  sub-acute,  or  the  chronic,  (if  the  term  please  better,) 
forms  of  rheumatism  ;  for  we  must  insist,  that  pain  in  a  particular 
part,  and  this  aggravated  by  motion,  by  changes  of  the  weather, 
or  other  causes,    must  necessarily  arise  from  inflammation  of 
more  or  less  activity  ;  and  that,  until  the  part  be  freed  from  this 
inflammatory  condition,  it  cannot  recover.     Besides,  Dr.  Scuda- 
more  admits,  that  chronic  rheumatism  appears  as  the  original 


RHEUMATISM.  763 

form  of  the  disease,  in  persons  who  have  passed  the  middle 
period  of  life;  and  from  hence  we  conclude,  that  though  from 
the  diminished  sensibility  of  the  tissues  involved  in  this  disease, 
they  are  less  disposed  to  "inflammatory  action,"  they  are  not 
exempt  from  it ;  for  to  what  other  cause  shall  we  attribute  the 
anatomical  changes  which  take  place  sometimes  in  this  disease, 
if  they  be  not  produced  by  inflammation ;  of  this  kind,  both  Dr. 
Scudamore  and  Morgagni  furnish  several  details,  as  happening 
to  the  parts  occupied  by  this  "sub-acute  or  chronic  inflamma- 
tion"— we  know  of  no  other  cause  capable  of  such  effects.  We 
think  then  we  have  every  right  to  conclude,  that  sub-acute,  (or 
chronic,)  rheumatism,  consists  of  a  low  inflammation  of  the  se- 
rous, or  white  vessels,  of  the  bursae,  tendons,  &c.  &c. 

Treatment. 

3448.  From  the  peculiar  grade  of  inflammation,  which  con- 
stitutes the  sub-acute  rheumatism,  it  very  seldom  happens  that  a 
vigorous  treatment  is  necessary,  or  even  proper — yet  cases  do 
occur,  in  which  it  becomes  essential  to  the  cure,  that  active 
means  should  be  used.  The  rule  which  we  have  laid  down  upon 
several  occasions,  namely,  that  the  name  of  the  disease  is  of  no 
moment;  that  it  furnishes  no  absolute  indication;  and  conse- 
quently is  not  to  govern  our  therapeutical  views,  should  con- 
stantly be  kept  in  sight  in  the  treatment  of  this  affection.  The 
state  of  the  system  must  always  be  first  attended  to — we  must 
determine  the  grade  or  quality  of  the  pulse;  ascertain  the  condi- 
tion of  every  other  portion  of  the  system  ;  especially,  the  state  of 
the  skin,  the  bowels,  the  biliary  secretion,  and  the  several  viscera 
of  the  body,  before  we  make  up  our  plan  of  treatment.  For  not- 
withstanding the  rheumatic  inflammation  has  not  called  the  cir- 
culatory system  into  sympathy,  there  may  be  other  causes  that 
have — therefore,  were  we  to  disregard  this  condition  of  the  ar- 
teries, however  unconnected  it  may  be  with  the  affection  we  are 
about  to  prescribe  for,  we  should  not  only  fail  to  cure  the  rheu- 
matism, but  should  run  the  risk  of  doing  serious  mischief  to  other 
portions  of  the  system,  as  certainly  as  if  the  excitement  was  pro- 
duced by  the  rheumatic  inflammation. 

3447.  It  will  therefore  follow,  though  general  bleeding  may 
very  seldom  be  required  in  sub-acute  rheumatism,  yet  it  may 
occasionally  be  absolutely  necessary  to  the  cure;  not  perhaps  be- 
cause we  think  it  will  directly  abate  the  local  inflammation,  but 
because  it  is  essential  to  the  cure,  that  the  too  vigorous  condi- 
tion of  the  pulse  be  abated,  that  other  remedies  may  be  safely 
and  efficiently  employed.  Therefore,  whenever  the  state  of  the 
system  is  such,  that  it  cannot  bear  stimulating  remedies,  with- 


764  RHEUMATISM. 

out  rousing  too  much  excitement,  they  should  never  be  used, 
however  beneficial  they  might  have  been,  had  this  condition  not 
been  present;  and  it  is  to  this  want  of  attention  to  the  state  of 
the  system,  that  we  may  mainly  ascribe  the  failures  in  the  treat- 
ment of  chronic  diseases.  For  it  should  constantly  be  borne  in 
mind,  that  this  form  of  rheumatism,  especially  in  people  advanc- 
ed in  life,  who  have  been  free  livers,  or  have  been  much  expos- 
ed to  changes  of  climate ;  will  often  be  complicated  with  affec- 
tions of  some  one  of  the  viscera,  or  other  structures  of  the  body, 
which  will  alter  the  usual  indications  for  rheumatism.  Thus, 
the  liver,  the  spleen,  the  kidneys,  the  lungs,  may  be  diseased; 
which  will  give  a  new  complexion  to  this  complaint.  Or  there 
may  be  mental  excitement,  or  great  nervous  irritability ;  there 
may  be  local  inflammation,  as  ophthalmia,  or  glandular  derange- 
ment, as  scrofula,  &c.  In  all  such  instances,  care  should  be 
taken  to  ascertain  the  influence  of  either  of  these  conditions  upon 
the  circulating  system,  before  the  prescription  is  made  for  the 
sub-acute  rheumatism,  if  we  hope  to  be  successful  in  the  treat- 
ment. In  Dr.  Scudamore's  work  upon  rheumatism,  there  are  a 
number  of  valuable  cases  illustrative  of  this  point,  arid  to  which 
we  refer  the  reader. 

Cupping  and  Leeching. 

3448.  Of  these  remedies,  we  have  already  spoken  at  par.  3410 
to  3422.  We  may  only  observe  in  addition,  that  we  have  found 
great  benefit  from  them,  where  there  was  no  great  evidence  of 
"  increased  vascular  action,"  except  what  might  be  inferred  from 
the  intensity  of  pain,  and  the  inability  to  suffer  the  motion  of  the 
part.      In  very  obstinate,  or  rather  in  very  long  standing  cases, 
where  the  location  of  the  disease  is  limited  to  a  small  extent,  and 
the  suffering  great,  we  never  fail  to  employ  one  of  these  remedies, 
and  we  think  always  with  advantage,  especially  if  the  part  can 
be  easily  covered  by  the  carded  wool,  a  few  hours  after  the  ope- 
ration. 

Local  Applications. 

3449.  There  are  very  many  substances  highly  extolled  for 
their  virtue  when  applied  to  the  pained  part  in  this  complaint — 
we  have  very  little  confidence,  however,  in  any  of  them,  except 
as  mere  temporary  applications  ;  their  effects  are  too  evanescent 
for  permanent  benefit,  and  too  uncertain  for  the  most  part,  for 
temporary  relief.     The  best,  we  believe,  are  the  rubefacients; 
and  the  best  of  these,  perhaps,  are  the  spirit  of  turpentine,  mus- 
tard, and  Cayenne  pepper.     We  have,  however,  found  the  most 


RHEUMATISM.  765 

prompt  and  decided  advantage,  from  a  liniment  composed  of 
equal  parts  of  sweet  oil,  laudanum,  and  vitriolic  aether,  when 
the  pain  fixes  itself  in  the  muscular  tissues — the  part  is  to  be 
bathed  with  it  every  hour  or  two,  until  it,  procure  relief;  and  it 
is  astonishing  sometimes  to  see,  with  what  speed  it  removes  those 
sudden  and  painful  attacks,  that  follow  exposure  to  cold.  Blis- 
tering has  rarely  been  successful  in  this  form  of  rheumatism, 
unless  repeated  perhaps  several  times.  Dr.  Scudamore  recom- 
mends, "  as  a  soothing  plaster,  equal  parts  of  the  emplastrum 
opii  and  ceratum  saponis;  and  if  the  pain  be  severe,  we  may  re- 
sort to  the  higher  power  of  belladonna,  and  in  the  same  way." 
p.  374. 

3450.  Of  the  various  baths  recommended,  as  the  warm,  va- 
pour, and  sulphureous,  we  can  say  nothing  positive,  evidence  be- 
ing so  contradictory  upon  this  point,  as  to  leave  their  powers 
altogether  undecided — every  practitioner  must  judge  for  himself 
upon  this  point  of  practice. 

3451.  A  number  of  other  remedies  are  recommended  for  the 
sub-acute  rheumatism,  as  mercury,  sarsaparilla,  guaiacum,  arse- 
nic, nitre,  bark,  sulphur,  and  colchicum.     Of  mercury  we  can 
say  very  little  in  its  favour,  unless  the  disease  has  had  a  venereal 
origin ;  and  even  then  it  has  not  proved  successful  but  in  combi- 
nation with  either  sarsaparilla  or  guaiacum,  or  both.  The  sarsa- 
parilla has  occasionally  been  highly  usefu.1,  in  the  recent,  sub- 
acute  rheumatism,  especially  when  this  has  been  the  secondary 
form  ;  that  is,  where  the  acute  has  terminated  in  this  way.     The 
compound  syrup  of  this  root,  as  prepared  by  Carpenter  and  Mar- 
shall, is  not  only  a  very  convenient,  but  a  very  efficacious  form 
of  this  medicine  ;  and  when  combined  with  an  eighth  of  a  grain 
of  the  corrosive  sublimate,  its  virtues  become  very  much  exalted.* 
The  guaiacum,t  in  form  of  the  volatile  tincture,  is  much  and  de- 

"  When  the  sarsaparilla  is  not  used  in  the  forms  recommended  in  the  text, 
an  ounce  to  an  ounce  and  an  half  should  be  used  daily.  The  form  of  decoc- 
tion is  the  best — an  ounce  sliced  or  bruised,  with  half  an  ounce  of  liquorice- 
root  bruised,  should  be  simmered  in  three  half  pints  of  water  down  to  a*pint — 
when  cool,  strain  it — a  wine-glassful  every  two  hours. 

f  The  tincture  we  employ  is  a  little  different  from  the  officinal  preparation; 
we  will  therefore  subjoin  the  formula. 


R.  Pulv.  gum  guaiac.  -        %iv 

Pulv.  pimento         -        -        gj. 
Carbon,  sodae  -         -         Zij 


Sp.  vin.  ten.  - 


IS. 


Take  Powdered  gum  guaia- 
cum -        4  ounces. 
Powdered  allspice      1  ounce. 
Soda           -        -        2  drachms. 
Proof  spirit        -        1  pound. 


Dig. 

Digest  for  several  days. 

When  about  to  be  used,  add  the  volatile  spirit  of  ammonia  in  the  proportion 
of  two  drachms  to  six  ounces  of  the  tincture — from  one  to  three  tea-spoonfuls 
three  or  four  times  a  day  in  sweetened  milk,  or  Sherry  wine. 


766  RHEUMATISM. 

servedly  esteemed  in  this  complaint,  when  given  in  sufficient 
doses,  persevered  in  duly,  and  when  there  is  not  the  slightest 
preternatural  excitement  in  the  arterial  system.  Arsenic,  in  the 
form  of  Fowler's  solution,  in  six  or  eight  drop  doses,  three  or 
four  times  a  day,  has  been  found  highly  serviceable  sometimes — 
we  think,  however,  that  it  is  most  useful  when  the  disease  seems 
to  obey  a  periodical  movement.  Nitre  has  also  been  highly  ex- 
tolled in  acute  rheumatism ;  especially  by  Dr.  Brocklesby,  who 
gave  it  in  fearful  doses  in  this  disease.*  Of  its  utility  in  very 
large  doses  in  the  acute  or  active  stage,  we  can  say  nothing  from 
our  own  experience,  though  we  have  employed  it  frequently  and 
pretty  largely  in  the  sub-acute,  and  particularly  where  it  has 
seized  upon  the  large  joints.  In  some  instances  it  has  afforded 
entire  relief,  after  many  other  remedies  had  been  employed  un- 
successfully; and  we  think  it  will  rarely  fail  to  afford  relief 
should  it  fail  to  effect  a  cure.  It  is  most  successful  in  young  and 
middle-aged  subjects.  Bark  we  have  never  derived  the  slightest 
advantage  from.  Sulphur,  in  small  doses,  and  persevered  in,  has 
been  found  occasionally  highly  serviceable  in  long  protracted 
cases. t  Colchicum  has  been  alternately  lauded  and  condemned 
'in  this  disease;  our  own  experience  declares  in  favour  of  it,  espe- 
cially in  the  commencement  of  the  sub-acute,  and  in  the  subdued 
acute  forms,  and  in  females.  Thirty  to  forty  drops  of  the  vinous 
tincture  of  the  seeds  should  be  given  every  four  hours — it  may 
be  continued  with  advantage  for  some  time,  provided  it  does  not 
sicken  or  purge  too  much.J 

*  We  use  nitre  in  the  following  manner: — 


R.  Sal.  nitre      -        -        -  |j. 

Sp.  vin.  camph.    -        -  3J. 

Aq.  font.      ...  Jfeiss. 
f.  sol. 


Take  Saltpetre  1  ounce. 

Camphorated  spirit     1  ounce. 
Water        -        -        1£  pound. 
Dissolve. 


Of  this,  a  wine-glassful  is  to  be  taken  three  or  four  times  a  day — if  it  disagree 
with  the  stomach,  let  the  quantity  be  reduced — and  let  the  first  dose  be  taken 
an  hour  after  breakfast. 

f  The  milk  of  sulphur  is  to  be  mixed  in  syrup  of  any  kind — a  tea-spoenful 
of  the  mixture  to  be  taken  morning,  noon,  and  evening;  if  it  purge  too  much, 
diminish  the  dose;  increase,  if  too  little. 

t  A  curious  fact  from  the  use  of  colchicum  is  said  to  have  developed  itself 
in  the  practice  of  Dr.  Buckner,  namely,  its  power  over  the  salivary  glands.  Dr. 
B.  relates  a  case  in  which  it  produced  a  very  profuse  salivation — "  the  discharge 
was  so  copious,  that  the  patient  was  convinced  he  had  '  spit  half  a  gallon'  in 
less  than  twenty -four  hours."  We  have  never  witnessed  this  effect  ourselves, 
though  we  have  given  this  medicine  in  pretty  full  doses,  and  continued  them 
for  some  time. 


GOUT.  767 


CHAPTER  XVI. 

GOUT. 

3452.  IN  treating  of  this  disease  we  shall  confine  ourselves 
very  much  to  practical  considerations;  leaving  the  speculative 
parts  to  the  management  to  those,  who  treat  professedly  of  it. 

3453.  This  disease  has  received  its  name  from  a  hypothetical 
view  of  its  cause;  namely,  a  distillation,  or  afflux,  guttatim,  of  a 
particular  humour,  in  the  part  affected;  which  is  worthy,  Guil- 
bert  says,  of  the  barbarous  age  in  which  it  originated.  The  Greeks 
called  it  arthritis,  because  it  is  wont  to  attack  the  joints ;  while 
Dr.  Cullen  named  it  podagra,  because  he  thought  the  seat  of  re- 
gular, or  idiopathic  gout,  was  in  the  foot. 

3454. ,  This  disease  has  been  divided  into  four  species: — 1. 
Podagra  regu/aris,  or  regular  gout.  2.  Podagra  atonica,  or 
atonic  gout.  3.  Podagra  retrograda,  or  retrocedent  gout.  4. 
Podagra  abberans,  or  wandering  gout. 

1.  Regular  Gout. 

3455.  In  this  form  the  inflammation  attacks  the  joint  most 
commonly  of  the  great  toe ;  is  of  sufficient  intensity,  or  vivid- 
ness; and  after  having  continued  a  certain  time,  (about  two 
weeks,)  gradually  disappears ;  the  patient  recovering  his  usual 
health,  or  fancies  it  even  improved.    It  is  generally  agreed,  that 
Sydenham's  description  of  this  complaint  is  so  complete  in  all 
its  parts,  as  to  leave  nothing  to  be  desired  on  this  head ;  he  him- 
self having  been  subject  to  it  four-and-thirty  years. 

3456.  He  says,  "  the  regular  gout  generally  seizes  in  the 
following  manner ;  it  comes  on  a  sudden  towards  the  close  of 
January,  or  the  beginning  of  February,  giving  scarce  any  sign 
of  its  approach,  except  that  the  patient  has  been  afflicted,  for 
some  weeks  before,  with  a  bad  digestion,  crudities  of  the  sto- 
mach, and  much  flatulency  and  heaviness,  that  gradually  increase 
till  the  fit  begins;  which  is  preceded  for  a  few  days  by  a  numb- 
ness of  the  thighs,  and  a  sort  of  descent  of  flatulencies  through 
the  fleshy  parts  thereof,  along  with  convulsive  motions;  and  the 
day  preceding  the  fit  the  appetite  is  sharp,  but  preternatural. 
The  patient  goes  to  bed,  and  sleeps  quietly  until  about  two  in 
the  morning,  when  he  is  awakened  by  a  pain,  which  usually 
seizes  the  big  toe,  but  sometimes  the  heel,  the  calf  of  the  leg,  or 
the  ankle.    The  pain  resembles  that  of  a  broken  bone,  and  is  at- 
tended with  a  sensation,  as  if  water  just  warm  was  poured  upon 


768  GOUT. 

the  membranes  of  the  part  affected  ;  and  these  symptoms  are  im- 
mediately succeeded  by  a  chilliness,  shivering,  and  a  slight  fever. 
The  chilliness  and  shivering  abate  in  proportion  as  the  pain  in- 
creases, which  is  mild  in  the  beginning,  but  gradually  more  vio- 
lent every  hour,  and  comes  to  its  height  towards  evening,  adapt- 
ing itself  to  the  numerous  bones  of  the  tarsus  and  metatarsus, 
the  ligaments  whereof  it  affects;  sometimes  resembling  a  tension 
or  laceration  of  those  ligaments,  sometimes  the  gnawing  of  a  dog, 
and  sometimes  a  weight  and  coarctation,  or  contraction  of  the 
membranes  of  the  parts  affected,  which  become  so  exquisitely 
painful,  as  not  to  endure  the  weight  of  the  clothes,  nor  the  shak- 
ing of  the  room  from  a  person's  walking  briskly  therein.  And 
hence  the  night  is  not  only  passed  in  pain,  but  likewise  with  a 
restless  removal  of  the  part  affected  from  one  place  to  another, 
and  a  continual  change  of  its  posture.  Nor  does  the  perpetual 
restlessness  of  the  whole  body,  which  always  accompanies  the 
fit,  and  especially  in  the  beginning,  fall  short  of  the  agitation  and 
pain  of  the  gouty  limb.  Hence  numberless  fruitless  endeavours 
are  used  to  ease  the  pain  by  continually  changing  the  situation 
of  the  body,  and  the  part  affected,  which,  notwithstanding,  abates 
not  till  two  or  three  in  the  morning,  that  is,  till  after  twenty- 
four  hours  from  the  first  attack  of  the  fit;  when  the  patient  is 
suddenly  relieved." 

3457.  "And  being  now  in  a  breathing  sweat,  he  falls  asleep, 
and  upon  waking  finds  the  pain  much  abated,  and  the  part  affect- 
ed to  be  then  swelled,  whereas  before,  only  a  remarkable  swel- 
ling of  the  veins  thereof  appeared,  as  is  usual  in  all  gouty  fits." 
After  this  he  observes,  that  the  other  foot  becomes  affected,  which 
relieves  the  first,  provided  there  be  much  pain  in  the  second  foot; 
and  what  is  usually  termed  a  fit  of  the  gout  is  made  up  of  a  num- 
ber of  these  small  fits.     The  common  period  of  a  fit  in  healthy 
constitutions  is  about  fourteen  days. 

3458.  During  this  period  the  urine  is  scanty,  and  high-colour- 
ed; depositing  "a  kind  of  red,  gravelly  sediment."   Loss  of  ap- 
petite, chilliness  towards  evening,  and  a  general  uneasiness  at- 
tends the  whole  fit.  When  the  fit  is  about  to  terminate,  a  violent 
itching  seizes  the  foot,  especially  between  the  toes,  and  the  skin 
desquamates.     The  fit  over,  the  appetite  and  strength  sooner  or 
later  return,  as  the  fit  may  have  been  more  or  less  severe ;  and 
the  next  fit  may  be  sooner  or  later  in  its  recurrence ;  "  for  if  the 
last  fit  proves  very  violent,  the  next  will  not  attack  the  patient 
till  the  same  season  of  the  year  returns  again." 

3459.  This  is  the  history  of  a  fit  of  regular  gout;  but  its  course 
and  symptoms  may  be  changed  by  bad  management,  or  by  its 
long  continuance,   and  then  becomes  the  atonic  gout  of  Dr. 
Cullen. 


GOUT.  769 


2.  Jltonic  Gout. 

3460.  This  is  attended  with  atony  of  the  stomach,  or  some 
other  internal  part.     The  accustomed  inflammation  of  the  joints 
may  not  take  place ;  or  take  place  very  transiently  ;  or  become 
fugitive,  alternating  with  indigestion,  or  other  marks  of  atony. 
When  this  takes  place  it  forms  the 

3.  Retrograde,  or  Retrocedent  Gout, 

3461.  Of  the  same  author.  This  may  have  been  attended  with 
the  usual  inflammation  of  the  joints,  but  not  in  its  usual  degree, 
or  with  usual  pain;  but  this  suddenly  abates,  while  some  internal 
part  becomes  the  seat  of  the  affection.  And  when  the  gouty  dia- 
thesis produces  inflammation  in  some  internal  part,  it  constitutes 
the  third  variety,  or  the 

4.  Misplaced  Gout. 

3462.  In  this  variety,  the  articular  inflammation  and  pain  are 
absent;  and  evidences  of  this  affection  are  exhibited,  in  other  por- 
tions of  the  body. 

3463.  It  is  not  an  absolute  security  against  the  other  forms  of 
gout,  that  this  has  observed  a  regular  shape  previously,  as  many 
causes  seem  capable  of  producing  the  aberrations  above  named; 
as  the  powerful  operation  of  the  predisposing  causes,  which  may 
be  any  thing  capable  of  producing  debility;  irregularities  in  diet; 
indulgence  in  acescent  drinks  and  food ;  passions  or  emotions  of 
the  mind;  improper  treatment;  &c.     But  for  the  most  part  in 
good  constitutions,  the  gout  observes  a  periodicity ;  which  how- 
ever may  differ  in  different  individuals;  some  will  not  have  a 
return  of  it  but  at  the  intervals  of  years ;  others  more  frequently, 
and  some  very  often. 

3464.  As  age  advances,  and  as  the  paroxysms  may  have  been 
more  or  less  severe,  or  more  or  less  frequently  repeated,  will 
be  the  reduction  of  strength,  and  the  alteration  of  the  natural 
and  healthy  functions.     The  stomach  and  the  extremities  seem 
principally  to  suffer;  the  first  by  indigestion,  and  the  latter  by 
stiffness,  and  chalk  stones,*  which  sometimes  ulcerate  the  skin 
which  covers  them. 

*  These  articular  products  have  been  examined  by  Vauquelin;  they  are 
found  to  consist  principally,  1st,  of  the  urate  of  soda;  2d,  a  small  quantity  of 
the  urate  of  lime;  3d,  the  phosphate  of  lime$4th,  a  fibrous  animal  matter. 

97 


770  GOUT. 


Proximate  Cause. 

3465.  Of  the  proximate  cause  of  gout,  many  opinions  have 
been  formed  ;  some  sufficiently  probable,  others  absurd,  and  all 
possibly  wide  of  the  truth.     We  shall  not  enter  therefore  into 
their  enumeration,  as  none  have  appeared  satisfactory  to  us.  One 
circumstance  however  we  think  we  may  insist  upon  ;  namely, 
that  the  inflammation  accompanying  gout,  (whether  it  consist  of 
this  or  not,  we  cannot  say,)  is  peculiar, T)r  sui  generis;  this,  the 
whole  phenomena  of  the  disease  seems  to  prove,  such  as  the 
production  of  chalk  stones,  the  peculiar  pain,  its  duration,  and 
its  sudden  disappearance,  as  well  as  its   translation   to   other 
parts,  &c. 

Diagnosis. 

3466.  Gout  cannot  be  well  confounded  with  any  other  disease 
than  rheumatism;  we  have,  in  treating  of  this  latter  disease,  run 
a  parallel  between  them.  And  in  addition  to  the  diagnoses  there 
laid  down,  we  may  add  the  following:  1.  Gout  is  evidently,  in 
many  instances,  hereditary*  and  constitutional ;  rheumatism  is 
never  hereditary,  though  it  may  be  constitutional.     2.  Gout  is 
excited  many  times  without  any  evident  cause  ;  rheumatism  re- 
quires the  application  of  cold,  or  some  other  agent.     3.  Gout  is, 
(perhaps,)  invariably  preceded  by  forewarnings,  that  decidedly 
herald  the  attack,  such  as  flatulency,  languor,  indigestion ;  rheu- 
matism has  no  such  premonitions.     4.   Gout  generally  attacks 
the  smaller  joints ;  rheumatism  usually  assails  the  larger.  5.  Gout 
is  always  attended  by  a  peculiar  shining  redness ;  rheumatism  is 
not,  or  but  rarely,  and  then  it  is  much  more  diffused.     6.   Gout 
very  frequently  produces  chalk  stones ;  rheumatism,  strictly  so 
called,  perhaps  never. 

Predisposing  Causes. 

3467.  Th»  imputed  predisposing  causes  are  numerous,  but  all 
of  them  are  not  well  ascertained.     Excesses  of  every  kind,  in 
eating  and  drinking,  idleness,  or  deficient  exercise,  particular 
drinks,  as  the  thin  acid  wines,  lemonade  or  punch  habitually  in- 
dulged in,  cider  and  beer,  &c.  &c. 

•  Dr.  Scudamore's  inquiry  into  the  hereditary  nature  of  gout,  renders  it  pro- 
bable, that  it  is  not  perpetuated  so  frequently  by  this  cause  as  has  generally 
been  imagined,  as  the  cases  from  an  hereditary  cause  exceed  the  acquired  by 
only  one-third;  yet  it  may  be  said  with  the  strictest  propriety  to  be  hereditary 
in  many  instances. 


GOUT.  771 


Exciting  Causes. 

3468.  Gout  very  often  shows  itself  without  any  apparent  ex- 
citing cause;  this  may  especially  happen  at  the  periods  at  which 
it  is  wont  to  return,  from  some  inscrutable  law  of  the  system  as 
regards  this  disease;  but  it  may  be  provoked  to  return  at  unac- 
customed times*  by  long  watching,  long  fasting,  excessive  fa- 
tigue, grief,  passions  or  emotions  of  the  mind,  especially  anger 
and  grief.     It  may  also  be  provoked  by  mechanical  causes,  as 
sprains,  and  pressure  from  tight  shoes  or  boots.    We  once  knew 
a  severe  attack  produced  in  a  gentleman,  by  jumping  from  his 
carriage  instead  of  descending  by  the  steps. 

Prognosis. 

3469.  Of  the  prognosis  of  gout  little  need  be  said,  as  it  is  sel- 
dom or  never  dangerous,  when  its  attack  is  regular,  and  main- 
tains its  position  in  the  extremities.     But  as  constitutional  dis- 
turbance is  almost  always  excited,  it  may  chance  to  be  rather 
excessive,  and  the  degree  of  fever  may  become  a  cause  of  alarm. 
If  this  happen,  the  prognosis  will  almost  be  the  prognosis  of  fe- 
ver; therefore,  when  this  befalls  a  good  constitution,  if  there  be 
a  clean  tongue  after  it  has  been  otherwise,  a  return  of  appetite, 
evacuations  natural,  the  skin  soft,  the  urine  throwing  down  a  la- 
teritious  sediment,  a  subsidence  of  arterial  and  nervous  irritation, 
a  diminution  of  the  local  inflammation  and  swelling,  we  may  look 
upon  the  case  as  about  to  terminate,  and  that  favourably. 

3470.  The  unfavourable  signs  are,  unusual  disturbance  of  the 
alimentary  canal,  a  feeble  or  exhausted  constitution  or  system, 
fluctuation  in  the  pained  parts,  disposition  to  metastasis,  inquie- 
tude of  mind,  &c. 

Pathological  Changes. 

3471.  The  most  remarkable  pathological  derangements  in  the 
parts  affected  by  gout,  are  anchyloses  of  the  smaller  joints  ;  thick- 
enings of  the  various  fibrous  structures  surrounding  them ;  depo- 
sitions of  chalky  concretions ;  and  occasionally,  the  same  kind  of 
product  is  discovered  ki  the  bladder. 

Treatment. 

3472.  We  scarcely  dare  to  talk  of  the  cure  of  gout,  whether 
it  be  hereditary  or  acquired.     The  most  we  can  aspire  to,  is  to 
diminish  the  intensity  of  suffering  by  proper  means  during  the 


772  GOUT. 

paroxysm,  and  perhaps  to  mitigate  the  violence  or  abridge  the 
duration  of  subsequent  attacks. 

Purging. 

3473.  During  the  paroxysm,  "  patience  a,nd  flannel"  are  ge- 
nerally recommended  as  the  only  resources ;  but  experience  am- 
ply proves  the  value  of  other  means  during  this  period.    Among 
these,  purging  appears  the  most  useful,  though  so  formally  pro- 
hibited by  Sydenham.  When  this  is  determined  on,  a  few  grains 
of  calomel  should  be  given,  followed  in  two  or  three  hours  by 
two  or  three  tea-spoonfuls  of  magnesia,  provided  the  calomel 
has  not  operated  previously ;  and  the  further  use  of  cathartic  me- 
dicine should  be  recurred   to,  if  the  pain  and  febrile  irritation 
continue.     We  are  aware  that  this  plan  has  been  objected  to  as 
injurious;  because,  it  is  declared,  that  gout  is  an  effort  to  expel 
something  morbid,  and  therefore  should  not  be  meddled  with. 
Upon  this  point  much  remains  to  be  proved;  and  it  is  rarely  safe 
to  rely  upon  theory,  when  experience  is  in  opposition  to  it.     It 
must  however  be  borne  in  mind  that  purging  is  only  recommend- 
ed during  the  intensity  of  the  paroxysm,  for  upon  its  decline  we 
do  not  think  it  so  useful ;  not  because  we  fear  a  recal  of  the  dis- 
ease,* but  because  it  does  not  appear  to  hasten  convalescence,  if 
the  bowels  have  been  amply  emptied  by  previous  purging.  And 
in  this  respect,  gout  appears  but  to  follow  the  course  of  every 
other  acute  disease.     Besides,  it  is  well  known  that  a  paroxysm 
of  gout  is  much  relieved,  or  is  found  not  unfrequently  to  termi- 
nate, by  some  of  the  affections  of  the  bowels,  as  cholera  or  diar- 
rhoea ;  and  that  constipation  is  sure  to  aggravate  as  well  as  pro- 
long the  fit.     For  this  practice,  the  authority  of  Hippocrates, 
Musgrave,  Cheyne,  Scudamore,  and  others  might  be  cited;  but 
perhaps  the  effects  of  the  "Eau  Medicinale,"  colchicum,  hermo- 
dactyle,  &c.  the  powers  of  which  to  relieve  this  disease  have 
long  been  acknowledged,  may  be  looked  upon  as  additional  evi- 
dence of  the  good  effects  of  purging  during  the  fit  of  gout. 

3474.  Dr.  Scudamore  speaks  favourably  of  a  similar  composi- 
tion to  that  recommended  for  rheumatism,  (par.  3425.)     If  this 
have  any  advantage  over  the  cathartics  in  common  use,  it  must, 
we  presume,  depend  upon  the  colchicum  that  enters  into  its 
composition ;  and  we  are  disposed  to  believe,  that  it  is  a  useful 
addition,  especially  in  the  commencement  of  the  paroxysm,  as 
the  efficacy  of  this  medicine  in  checking  gout,  when  given  in 
the  commencement  of  the  fit,  seems  to  be  generally  admitted. 

*  Dr.  Heberden  is  of  opinion,  however,  that  a  purge  given  at  the  close  of  a 
fit  of  gout,  will  recal  it. — Commentaries,  p.  37. 


GOUT.  773 


Emetics. 

3475.  Emetics  have  also  been  employed  for  the  relief  of  gouty 
paroxysms — of  their  efficacy,  we  can  say  nothing  from  our  own 
observation.     The  usefulness  of  emetics  in  gout  is  by  no  means 
as  well  established  as  that  of  cathartics,  though  formerly  they 
were  in  considerable  use.     We  are  of  opinion,  however,  they 
can  only  be  distinctly  useful  where  gastric  embarrassment  may 
exist — when  this  is  evident,  a  few  grains  of  ipecacuanha  may  be 
given,  perhaps  with  advantage.     Rush,  Scudamore,  and  Small, 
are  among  those  who  have  recommended  them,  in  modern  times. 

Bleeding. 

3476.  Let  our  pathological  views  of  gout  be  what  they  may, 
one  thing  will  be  acknowledged  by  all,  that  it  presents  much  va- 
riety in  different  constitutions,  age,  sex,  season  of  the  year,  lo- 
cation, &c.  and  consequently  remedies  must  be  suited  to  the  par- 
ticular state  of  the  system.     In  every  other  disease,  the  state  or 
force  of  the  arterial  system  must  constantly  be  kept  in  view,  if 
we  hope  to  prescribe  with  advantage  to  our  patient — the  same 
observance  is  not  less  necessary  in  gout ;  for  in  this  country,  this 
disease  often  requires  depletion  from  the  blood-vessels.     This 
may  be  done  from  the  arm,  in  cases  of  high  excitement,*  and 
from  near  the  part,  when  the  disease  attacks  the  larger  joints  and 
the  local  inflammation  is  very  considerable.   We  once  witnessed 
an  instance  of  this  kind,  in  a  plethoric,  active  young  man,  who 
had  unexpectedly  brought  on  a  fit  of  the  gout,  from  over-exer- 
cise in  shooting.     It  attacked  the  ankle-joint,  from  which  the 
inflammation  spread  nearly  to  the  toes  and  half  way  of  the  calf 
of  the  leg;  the  pain  was  exquisite ;  so  much  so  as  to  deprive  him 
of  all  power  to  move  the  limb,  and  to  rob  him  of  all  rest.  Forty 
leeches  were  placed  on  the  outer  margin  of  the  redness,  with 
marked  advantage  and  relief;  after  this,  the  fit  ran  its  usual  course 
without  more  than  ordinary  trouble. 

3477.  In  recommending  the  abstraction  of  blood  in  gout,  we 
do  not  offer  it  as  a  constant  remedy  in  this  disease;  we  only  in- 
sist that  where  inflammatory  action  runs  high,  this  mode  of  de- 

*  Dr.  Rush  informs  us,  that  in  one  case,  he  took  away  sixty  ounces  of  blood; 
and  in  another  thirty  ounces,  (Works,  Vol.  II.  p.  257.)  Dr.  Rush  says  that 
bleeding  in  gout,  lessens  pain;  prevents  congestions,  and  exhaustion,  and 
shortens  the  duration  of  the  fit,  (Ibid.)  Dr.  Heberden  says,  "  one  person  was 
bled,  by  his  own  direction,  in  every  fit  of  the  gout  for  six-and-thirty  years;  and 
bleeding  was  a  frequent  practice  with  another  in  the  agony  of  the  paroxysm, 
which  it  always  abated  so  as  to  bring  on  a  sound  and  refreshing  sleep  without 
any  manifest  ill  effect."— Commentaries,  p.  45. 


774  GOUT. 

pletion  is  as  proper  in  gout,  as  in  any  other  affection.  There 
are  cases  doubtless  in  which  this  operation  is  not  required;  and 
others  in  which  it  might  be  hurtful ;  but  this  is  precisely  the  case 
with  almost  every  other  disease.  Hitherto,  we  have  seen  no- 
thing in  this  disease,  that  forbids  it  to  be  treated  upon  general 
principles,  unless  perhaps  it  be  the  employment  of  cold  to  the 
part,  as  recommended  by  Kinlake.  We  once  knew  a  perma- 
nent affection  of  the  stomach  produced  in  a  first  attack,  by  eva- 
porating from  the  pained  part,  vitriolic  ether — it  very  quickly 
relieved  the  gouty  symptoms,  but  this  was  followed  by  severe 
colics,  which  continued  to  return  occasionally  for  years — the 
gout  never  returned  to  the  ankle  again. 

Opium. 

3478.  We  believe  the  practice  of  administering  opium  in  any 
form  in  gout,  is  now  very  much  abandoned,  as  the  principle 
which  should  regulate  its  use,  is  better  understood.  It  is  natu- 
ral to  seek  relief,  under  such  intense  suffering  as  a  paroxysm 
of  gout  produces ;  and  nothing  in  speculation  bids  fairer  to  afford 
this,  than  opium  ;  but  unfortunately  for  the  afflicted,  this  expecta- 
tion is  not  found  to  be  realized  by  experience  at  the  wished-for 
moment,  nor  in  the  hoped-for  degree.  But  this  failure,  in  many 
instances  at  least,  has  arisen  from  the  proper  condition  of  the 
system  not  being  selected  for  its  exhibition,  rather  than  from  any 
pathological  incompatibility  ;  for  we  are  certain  there  is  a  period 
in  the  fit,  that  this  medicine  proves  kind,  especially  when  com- 
bined with  the  colchicum — and  this  period  is,  when  the  inflam- 
matory action  is  well  subdued,  and  not  before.  We  are  in  the 
habit  of  giving  at  bed-time,  and  occasionally  at  other  times,  if 
pain  require  it,  the  following  draught,  with  much  advantage. 

R.  Tinct.  opii  acet.  gut.  xx. 


Tinct.vin.  esem.colch.  gut.  xl. 
Sacch.  alb.  -        gss. 

Aq.  font.       -        -        jfj. 
M. 


Take  Acetated  tincture  of 

opium  or  black  drop  20  drops. 
Vinous  tincture  of 

colchicum  seeds  40  drops.* 
White  sugar  -  £  drachm. 
Water  1  ounce. 

Mix. 


3479.  Of  the  other  narcotics  recommended  by  several  of  the 

*  A  preference  has  lately  been  given  to  this  preparation  of  the  colchicum, 
and  perhaps  justly — it  appears,  at  least,  to  be  more  mild  in  its  operation,  than 
the  infusion  of  this  root,  and  is  equally  efficacious  in  warding  off,  or  removing 
a  gouty  paroxysm.  This  perhaps  may  be  owing  to  a  smaller  quantity  of  the 
extractive  matter,  being  present  in  the  vinous  tincture  of  the  seeds,  than  in  tho 
infusion  of  the  root;  for  if  we  can  rely  upon  the  experiments  of  Sir  E.  Home, 
it  was  constantly  found  that,  a  dose  of  the  infusion  containing  the  deposit  had 
a  more  powerful  operation  upon  the  system;  especially  the  bowels,  than  when 


it  was  exhibited  without  it. 


GOUT.  775 

British  writers,  as  the  cicuta,  hyoscyamus,  stramonium,  bella- 
donna, &c.  we  can  say  nothing  in  this  disease;  for  upon  other 
occasions,  they  have  never  failed  to  disappoint  the  hope,  that  they 
might  possess  an  advantage  over  opium. 

Sudorifics. 

3480.  We  have  never  found  sudorifics  answer  any  valuable 
purpose  in  gout,  and  therefore  never  specifically  prescribe  them — 
indeed,  we  have  thought  theyTiave  rather  exposed  the  patient 
to  inconvenience,  than  to  have  afforded  him  relief;  though  we 
confess  we  have  seen  ten  grains  of  Dover's  powder  act  very 
kindly,  when  a  dryness  of  skin,  and  watchfulness  rather  than 
severe  pain,  has  kept  the  patient  awake.     In  a  word,  sudorifics 
do  not  appear  to  be  more  efficacious  in  their  operation  in  gout 

than  they  are  found  to  be  in  rheumatism. 

\ 

Diuretics. 

3481.  A  fit  of  gout  has  many  times  terminated  by  a  copious 
discharge  of  urine;  it  has  therefore  been  supposed,  that  this  class 
of  medicines  must  be  useful  in  this  complaint.     However  natu- 
ral the  suggestion,  diuretics  have  as  far  as  we  have  observed, 
but  a  limited  influence  upon  the  active  part  of  a  paroxysm  of 
gout,  though  we  have  never  witnessed  any  unfriendly  conse- 
quences to  arise  from  their  exhibition.   The  mode  by  which  this 
disease  finishes  its  career,  or  rather  the  evidence  that  it  almost 
always  presents  us,  that  it  has  done  so,  (namely,  the  urine  throw- 
ing down  the  lateritious,  or  brick-dust  sediment,)  would  seem 
to  encourage  a  belief,  that  diuretics  are  necessary  in  this  com- 
plaint.   But  it  should  be  remembered,  that  we  can  neither  force 
nor  solicit  the  kidneys  by  diuretics  to  imitate  this  apparently 
critical  peculiarity  in  the  urine,  however  desirable  this  might 
be — for  it  is  an  inimitable  process  of  nature. 

3482.  As  a  general  rule,  we  are  therefore  of  opinion,  that  the 
only  really  valuable  and  certain  diuretics,  are  such  remedies  as 
will  most  certainly  abate  the  violence  of  the  inflammatory  action 
of  the  system ;  and  these  are  found  to  be  purging,  and  occasion- 
ally blood-letting.     For  when  the  febrile  tumult  is  calmed,  pain 
abates;  and  the  urine  shows,  that  the  gouty  excitement,  is  about 
to  relent;  but  a  mere  increase  of  this  fluid,  proves  no  such  crisis 
to  be  at  hand,  be  its  quantity  ever  so  abundant. 

General  Remedies. 

3483.  But.  nothing  perhaps  proves  the  want  of  general  sue- 


776  GOUT. 

cess  in  the  regular  treatment  of  gout,  more  than  the  almost  uni- 
versal search  for  a  prompt,  or  rather  a  specific  remedy  for  its 
relief.  Many  have  been  the  nostrums,  purporting  to  be  infalli- 
ble cures;  but  like  almost  all  the  remedies  of  this  class,  they 
have  proved  infallible  in  every  case,  except  the  individual 
one,  in  which  their  power  is  put  to  the  test.  We  must  not, 
however,  resist  the  evidence  in  favour  of  the  ';  Eau  Medicinale," 
though  we  have  never  ourselves  prescribed  it;  its  celebrity 
throughout  Europe  in  this  case,  forbids  entire  scepticism.  In 
this  country,  its  employment  hitherto  has  been  limited ;  nor  are 
we  exactly  in  possession  of  the  opinions  of  the  physicians  of 
America,  respecting  its  powers ;  yet  sufficient  is  known,  to  ex- 
cite an  anxiety,  to  become  acquainted  with  its  composition. 
Many  conjectures  have  been  made  upon  this  point — but  none, 
we  believe,  on  which  reliance  should  be  absolutely  placed.  It 
has  been  said  to  consist  of  the  nicotiana,  gratiola,  veratrum,  ela- 
terium,  colchicum,  &c.  &c. 

3484.  This  medicine  acts  with  great  promptitude  we  believe, 
always ;  and  sometimes,  with  unprofitable  violence.     It  purges 
with  great  activity;  vomits  violently;  sweats  profusely:  or  runs 
off  by  urine,  copiously,  and  this  followed,  by  a  great  loss  of  mus- 
cular power.     But  during  this  varied,  and  severe  discipline,  it 
is  said,  the  pain  abates,  and  the  swelling  of  the  joint  subsides 
with  such  rapidity,  as  to  leave  the  patient  perfectly  relieved. 
But  notwithstanding  this  favourable  report,  we  find  many,  who 
declare  it  to  be  useless,  and  others  that  it  is  dangerous. 

3485.  My  friend  Dr.  Chapman  is  almost  the  only  practitioner 
in  this  city,  who  has  experience  in  the  use  of  the  "Eau  Medici- 
nale."     He  informs  us  he  has  tried  it  "in  five  or  six  cases  of 
gout  of  different  forms,  with  almost  constant  success."     In  a 
paroxysm  of  podagra  in  which  he  used  it,  he  says,  long  before 
nausea  or  purging  commenced,  "there  was  a  marked  mitigation 
of  pain,  and  a  corresponding  degree  of  composure,  resembling 
very  nearly,  the  state  induced  by  an  anodyne."' 

3486.  Dr.  Chapman  adds,  "  whether  the  repeated  use  of  this 
medicine  has  any  tendency  to  impair  the  tone  of  the  system, 
and  thereby  aggravate  the  mischief  it  is  intended  to  remove,  I 
have  not  sufficient  experience  to  decide. "     He  however  knew 
one  instance  in  which  it  had  been  used  occasionally  for  many 
years,  in  which  vigorous  health  was  preserved. t 

3487.  Analogy  of  effects,  has  led  to  a  belief,  that  colchicum  is 
the  basis  of  the  "  Eau  Medicinale  ;"t  whether  this  is  so  or  not, 

•  MS.  Lectures.  f  Ibld- 

*  The  experiments  of  Sir  E.  Home,  would  lead  as  very  strongly  to  the  be- 
lief that  they  are  identical.     The  effects  of  deleterious  doses  of  the  two  sub- 
stances were  precisely  the  same,  as  far  as  could  be  determined  either  by  the 


GOUT.  777 

remains  to  be  determined  ;  it  certainly  appears  to  manifest  con- 
siderable controul  over  the  gouty  paroxysm,  and  by  a  similar 
three-fold  operation;  namely,  cathartic,  diuretic,  and  sometimes 
emetic  effect.  Dr.  Scudamore  extols  the  following  draught:  — 


R.  Magnesia,  gr.  xv.  vel  xx. 

Sulph.  magnes.  ?  .      ,     .. 

Acet.  Colch.       5    aa'Sj'ad  ^ij. 

Aq.  font.  q.  s.  f.  haust. 


Take  Magnesia,         from  15  to  20  grs. 
Epsom  salt       ~)    •  .   - 
Vinegar  of  col-  £  each  from  1  to  2 

chicum        5       drachms' 
Water,  sufficient  to  make  into  a 
draught. 

This  may  be  repeated  several  times  a  day  if  necessary. 

Local  Applications. 

3488.  Many  local  'remedies  have  been  proposed  for  the  relief 
of  a  gouty  paroxysm  ;  but  none  we  believe  is  yet  discovered, 
that  is  both  effectual  and  safe.     Our  own  confidence  in  them  for 
this  reason,  is  extremely  limited;  there  are  but  two,  so  far  as  we 
have  witnessed,  that  are  both  innocent  and  effectual;  but  the  lat- 
ter advantage  it  must  be  confessed,  is  not  constant.     We  mean 
local  bleeding  as  directed  above,  and  warm  sweet  oil.  From  both 
these,  we  have  witnessed  occasionally  the  kindliest  effects  ;  and 
without  the  slightest  risk. 

3489.  Blisters  disappoint;  vapour  and  tepid  water  are  uncer- 
tain ;  evaporating  lotions  are  sometimes  mischievous,  (see  par. 
3477;)  escharotics  painful,  without  corresponding  utility;  and 

constitutional  symptoms  during  the  lives  of  the  animals,  or  the  appearances 
after  death.  —  Philosoph.  Magaz.  for  Dec.  1817. 

A  remarkable  effect  of  the  colchicum,  is  related  by  Dr.  Kuhn,  in  the  Revue 
Me"dicale  for  July  1830.  "  One  of  the  most  remarkable  effects  of  the  colchicum 
upon  the  urinary  secretion  of  persons  affected  with  arthritis  or  gout,  is  that 
which  was  observed  by  M.  Chelius,  and  recorded  in  the  Annales  Cliniques  of 
Heidelberg,  Vol.  III.  p.  345.  The  Professor  of  Heidelberg  has  found,  that 
while  patients  with  this  complaint  made  use  of  colchicum,  their  urine  under- 
goes changes  which  consist  in  a  striking  increase  of  the  proportion  of  uric  acid. 
The  following  are  the  results  of  the  examination  of  the  urine  of  a  patient  af- 
fected with  gouty  swellings  in  several  of  his  joints,  especially  in  his  knees,  so 
that  he  was  wholly  unable  to  move.  Before  the  employment  of  the  colchicum, 
the  uric  acid  contained  in  his  urine,  as  well  in  the  free  state  as  combined  with 
ammonia,  was  0.069?  on  the  fourth  day  of  the  employment  of  the  medicine,  it 
was  0.076;  on  the  eighth  day  0.091;  and  on  the  twelfth,  0.112;  so  that  the 
amount  of  the  acid  was  almost  doubled  in  a  period  of  twelve  days."  Similar 
results  were  obtained  by  M.  Chelius,  in  many  cases  of  the  same  nature,  in 
which  the  urine  was  analyzed.  "  These  results  are  very  important,  as  they  en- 
able us  to  understand  how  colchicum  produces  so  many  wonderful  cures  of 
gout;  is  it  not  in  fact,  by  eliminating  from  the  animal  oeconomy,  the  excess  of 
uric  acid,  which  in  this  complaint,  forms  the  chalky  concretions  of  the  joints. 
I  well  remember  having  heard  Mr.  Lobstein  say,  long  before  the  publication  of 
the  fact  observed  by  M.  Chelius,  that  he  had  succeeded  in  dissipating,  by  the 
aid  of  colchicum,  arthritic  concretions,  which  had  resulted  from  inveterate 
rheumatism."  —  North  JLmer.  Med.  and  Surg,  Journ.  for  Jan.  1831,  p.  234. 

98 


778  GOUT. 

cold  water  now  and  then  hazardous,  notwithstanding  the  high 
encomiums,  and  ingenious  reasoning  of  Dr.  Kinlake  to  the  con- 
trary. Dr.  Heberden  says,  that  "the  great  Dr.  Harvey,  as  I 
have  been  told  by  some  of  his  relations,  upon  the  first  approach 
of  gouty  pains  in  the  foot,  would  instantly  put  them  off  by 
plunging  the  leg  into  a  pail  of  cold  water."  He,  however,  adds, 
"I  do  not  recommend  Dr.  Harvey's  example  as  proper  to  be 
imitated,  though  it  is  known  he  lived  to  a  good  old  age."*  This 
practice  is  as  old,  even  as  Hippocrates,  in  one  form  or  other. 
We  confess  we  have  never  had  resolution  to  recommend  this 
course  to  any  of  our  patients;  not  from  simply  reasoning  upon 
this  subject,  for  this  should  never  be  put  in  direct  opposition  to 
experience;  but  because  experience  has  unquestionably  furnished 
a  number  of  disastrous  cases,  where  trial  was  made  of  this  re- 
medy. This  practice  was  much  canvassed  in  the  London  Me- 
dical and  Physical  Journal;  to  which  we  would  more  particularly 
refer,  were  the  work  at  hand,  to  enable  us  to  do  so. 

3490.  When  the  paroxysm  is  about  to  decline,  we  have  seen 
much  comfort  derived  from  the  carded  wool,  and  oil  silk,  as  re- 
commended for  rheumatism.   (See  par.  3439.) 

Regimen  during  the  Fit. 

3491.  From  what  has  been  said  on  the  general  nature  of  gout, 
it  may  at  once  be  inferred,  that  an  antiphlogistic  regimen  should 
be  strictly  observed  throughout  the  whole  course  of  the  disease. 
We  are  aware,  that  the  contrary  plan  is  recommended  by  some, 
and  followed  by  many;  we  have  no  right,  nor  do  we  pretend  to 
interfere  with  these  predilections,  as  the  penalties  attached  to 
such  choice,  are  all  their  own.     We  mean  only  to  caution  the 
young  practitioner  against  the  influence  of  authority,  and  the 
seduction  of  example,  when  they  are  opposed  by  reason,  and 
well-directed  observation.     Besides  a  regimen  strictly  antiphlo- 
gistic, the  patient  should  observe  rest  of  body,  and  court  tran- 
quillity of  mind — shun  all  irritation,  and  invite  quietude,  and  ab- 
straction, both  physical,  and  moral,  though  Dr.  Heberden  says, 
"I  have  known  several,  who  instead  of  nursing  a  beginning 
gout  with  warmth,  and  repose,  have  used  the  utmost  resolution 
and  exertion  in  moving  and  exercising  the  limb,  which  they 
found  themselves  gradually  able  to  do  more  and  more,  till  at 
last  they  recovered  its  perfect  use,  free  from  any  feelings  of  pain, 
and  without  any  manifest  ill  consequences."!    These  facts,  how- 
ever, are  to  be  received,  for  no  more  than  they  are  worth ;  for 
they  only  prove,  that  there  is  different  degrees  of  this  disease ; 

*  Commentaries,  p.  49.  f  Idem. 


GOUT.  779 

and  one,  so  slight,  as  to  be  overcome,  by  moral  courage,  and 
physical  exertion. 

3492.  But  let  us  not  be  understood  as  recommending  "  flan- 
nel," because  we  apprehend,  that  mischief  may  arise  from  "cold 
water.7'  Hitherto  we  have  never  had  good  reason  to  believe  that 
the  slightest  advantage  could  arise  from  keeping  the  parts  hot. 
We  perfectly  acknowledge  the  truth  of  the  judicious  Heberden's 
observation  upon  this  point.  "  Those  who  choose  to  invite  the 
stay  of  the  gout,  and  are  afraid  of  disturbing  its  repose  by  any 
motions  of  the  affected  limbs,  often  add  very  unnecessarily  to 
the  difficulty  of  moving  them,  by  the  quantity  of  flannel  in  which 
they  are  wrapped  up,  even  in  the  hottest  weather.  I  never  could 
see  any  reason  for  adding  at  all  to  the  usual  covering  of  the  limb, 
unless  its  extraordinary  tenderness,  or  the  severity  of  the  wea- 
ther, might  make  a  very  little  more  necessary  to  keep  off  the 
sensation  of  cold,  so  disagreeable  to  a  part  which  is  swelled  and 
in  pain."  p.  50. 

Jltonic  Gout. 

349 S.  We  have  already  partially  defined  the  atonic  gout,  (see 
par.  3460,)  to  which  we  shall  now  add,  that  in  constitutions  lia- 
ble to  this  form,  that  it  never  regularly,  or  but  very  rarely,  shows 
itself  to  be  a  local  affection  of  the  extremities,  like  the  regular 
gout.  It  may,  however,  at  some  one  period,  have  shown  a  dis- 
position to  regularity ;  but  either  a  feebleness  of  constitution,  or 
some  improper  treatment,  may  have  alienated  it  from  its  legiti- 
mate location.  In  consequence  of  this,  it  forsakes  its  inflamma- 
tory form,  and  assumes  various  ill-defined,  but  still  cognizable 
shapes. 

3494.  The  stomach  is  the  part,  that  most  frequently  suffers 
from  this  form  of  disease ;  this  declares  itself  by  the  loss  of  appe- 
tite, indigestion,  nausea,  vomiting,  acrid  and  sour  eructations, 
heartburn,  pain,  spasms,  flatulency,  &c.     To  these,  or  to  some 
of  them,  costiveness,  diarrhoea,  tormina,  and  windy  stools,  may 
be  added ;  and  not  unfrequently,  great  lowness  of  spirits,  or  an 
anxious  watching  of  every  rising  sensation,  with  the  most  gloomy 
forebodings ;  palpitation  of  the  heart,  especially  after  eating,  &c. 

3495.  Or  its  seat  may  be  the  brain ;  then  there  may  be  head- 
ache; tic  douloureux;  vertigo;  apoplexy;  palsy.     In  a  word,  .it 
may  affect  any  of  the  viscera;  each  of  which  will  discover  cha- 
racteristic symptoms,  when  under  the  influence  of  this  morbid 
diathesis. 

3496.  For  the  most  part,  however,  we  have  to  contend  with 
gastric  affections ;  the  nature  of  these  are  so  various,  and  so  mul- 
tiplied, that  no  regular  history  can  be  given  of  them,  nor  any 


780  GOUT. 

especial  plan  of  cure  laid  down.  The  principal  indications  how- 
ever, are  to  restore  the  impaired  tone  of  the  stomach ;  and  to 
counteract  unpleasant  symptoms,  as  they  arise. 

3497.  The  first  is  attempted  to  be  answered  by  tonics,  both 
vegetable  and  mineral ;  of  the  first,  the  bitters  stand  foremost. 
This  class  of  tonics  are,  however,  not  altogether  without  their 
disadvantages;  for  they  become  injurious,  when  too  long  persist- 
ed in,  in  whatever  degree  their  selection  may  be  varied.     Gen- 
tian, chamomile,  quassia,  columbo  root,  &c.  have  each  been  found 
useful  for  a  period,  after  which  they  either  cease  to  make  a  fa- 
vourable impression,  or  become,  from  their  stimulant  quality, 
hurtful.    The  mineral  tonics  are  less  exceptionable,  and  perhaps 
more  efficacious ;  besides,  having  less  injury  to  follow-a  long  per- 
severance in  their  use.     The  various  preparations  of  iron  are  the 
best ;  and  especially  when  occasionally  combined  with  ginger. 

3498.  The  occasional  distressing  symptoms  above  enumerated, 
are  to  be  met  by  their  appropriate  remedies;  but  as  they  almost 
always  arise  from  a  redundancy  of  acid,  and  this  generated,  or 
if  not  generated,  at  least  increased,  by  errors  in  diet,  the  most 
scrupulous  care  should  be  taken  to  guard  against  such  mischievous 
aberrations. 

3499.  To  relieve  the  acid  condition  of  the  stomach,  and  by 
this  means  abate,  (at  least  in  most  instances,)  the  severity  of 
sickness,  heartburn,  flatulency,  colicky  pains,  &c.  the  antacids 
should  be  employed,  pro  re  nata.    Sometimes  magnesia  or  mag- 
nesia and  rhubarb  are  the  most  eligible ;  this  obtains  where  cos- 
tiveness  exists ;  at  others,  the  vegetable  alkalies,  or  the  carbonate 
of  ammonia  will  be  best — the  former  where  no  lowness  of  spirits 
attend,  and  the  latter,  when  this  prevails.   But  for  constant  use, 
the  "alkaline  solution,  from  wood  ashes,"*  appears  to  answer 
best;  but  for  this  to  be  useful,  it  must  be  persisted  in  for  some 
time,  aided  by  a  well-regulated  diet. 

3500.  Of  the  diet  of  such  patients,  it  is  difficult  to  speak  with 
precision,  or  minute  detail;  for  much  must  be  left  to  the  habits 
and  condition  of  the  patient.   As  a  general  rule,  it  should  consist 
chiefly  of  the  animal  foods  found  most  easy  of  solution ;  as  beef, 
mutton,  venison,  rabbits,  turkeys,  chickens,  partridges,  phea- 
sants, oysters,  and  soft-boiled  eggs.      All  acescent  substances 

•  This  solution  is  made  by  burning  upon  a  clean  hearth,  young,  green 
hickory  wood.  When  reduced  to  ashes,  a  vessel  of  any  size  is  to  be  two-thirds 
filled,  if  the  hot  embers  be  used,  (which  is  best,)  if  the  cold,  half  filled;  as  much 
boiling  water  is  to  be  poured  upon  the  ashes  as  will  fill  the  vessel,  adding  pre- 
viously a  large  table-spoonful  of  clean  soot,  to  every  quart  of  the  water.  This 
must  be  stirred  by  a  piece  of  wood,  several  times  a  day,  for  four  or  five  days, 
and  then  permitted  to  settle.  Of  the  clear  lixivium,  from  a  wine-glassful  to  a 
gill  must  be  taken  half  an  hour  after  each  meal,  or  at  any  other  period,  at  which 
acidity  is  troublesome. 


GOUT.  781 

should  be  carefully  avoided,  especially  vinegar,  lemonade,  wine, 
cider,  beer,  &c.  Supper  of  no  kind  should  ever  be  indulged  in  ; 
and  the  best  drink  is  plain  water,  or  very  weak  brandy  and  wa- 
ter, if  water  alone  be  found  to  disagree.  But  notwithstanding 
every  attempt  to  define  rules,  much  must  be  left  to  the  idiosyn- 
crasies of  patients. 

3501.  The  body  should  be  carefully  and  warmly  clad;  espe- 
cially the  feet  and  legs — all  exposures  to  cold,  wet,  or  damps, 
should  be  diligently  shunned. 

Retrocedent  Gout. 

3502.  We  have  said,  (par.  3461,)  that  this  form  of  gout  may 
have  been  preceded  by  inflammation  of  the  joints;  but  not  in  the 
usual  degree,  or  with  the  usual  pain;  but  that  this  suddenly 
abates,  while  some  internal  part  becomes  the  seat  of  the  af- 
fection. 

3503.  When  gout  shifts  its  ground,  we  cannot  determine,  & 
priori,  where  or  on  what  part  it  may  fix  itself,  as  no  viscera  is 
secure  from  its  visitations.     The  stomach,  as  in  atonic  gout,  be- 
comes more  frequently  its  seat;  producing  therein  the  most  ex- 
quisite pain,  and  giving  rise  to  the  most  imminent  danger;  so 
much  so  sometimes,  that  death  ensues  in  a  short  time  after  its 
invasion.     The  most  excruciating  agony,  and  the  most  frightful 
spasms,  are  the  principal  phenomena  presented  by  this  change 
of  place  of  gout.     And  so  wayward  is  it  sometimes,  that  it  for- 
sakes the  stomach  and  attacks  the  brain  with  almost  the  rapidity 
of  lightning.    We  occasionally  attended  a  lady,  who  was  subject 
to  this  form  of  gout;  in  her,  we  have  known  it  seize  upon  the 
stomach  with  the  most  frightful  violence ;  after  continuing  there 
for  fifteen  or  twenty  minutes,  it  would  without  any  apparent 
cause  mount  to  the  brain,  and  in  an  instant  excite  ravings  like  a 
maniac.    While  here,  we  have  seen  handfuls  of  hair  deracinated 
from  the  head,  with  the  most  frantic  gestures,  and  every  other 
extravagance  that  characterizes  madness.     This  state  of  things 
however  would  not  be  more  permanent,  than  when  the  stomach 
was  the  seat  of  its  power ;  for  with  equal  speed  it  would  leave 
the  brain,  and  return  to  this  organ,  there  to  renew  its  fearful 
operations.     In  this  manner  it  would  continue  for  hours ;  to  va- 
cillating between  these  parts,  and  each  time  renewing  the  phe- 
nomena above  detailed.     But  what  was  the  most  astonishing  in 
these  frequent  and  rapid  metastases,  was  the  apparently  entire 
integrity  of  the  parts,  the  instant  this  Proteus  would  forsake 
them. 

3504.  In  another  case,  we  witnessed  as  remarkable,  but  not 


782  GOUT. 

as  sudden  metastases  to  the  heart,  the  lungs,  and,  (from  the  seat 
of  pain,)  to  the  colon ;  in  this  instance  the  brain  did  not  partici- 
pate in  these  translations. 

Treatment. 

3505.  When  the  stomach  is  the  part  affected,  we  are  some- 
times obliged  to  resort  at  the  same  moment,  to  very  opposite 
modes  of  treatment.  With  one  hand  we  are  liberally  abstracting 
blood,  while  with  the  other,  we  are  administering  opium,  (in 
some  form  or  other,)  ether,  brandy,  &c.    Nor  must  this  plan  be 
called  empirical  or  contradictory,  since  it  is  justified  by  expe- 
rience.    For  in  the  case  of  the  lady  above  mentioned,  it  was 
always  resorted  to,  and  always  sooner  or  later  successful.     We 
therefore  do  not  hesitate  to  recommend  this  seemingly  discordant 
practice.     The  cases  in   which   Dr.    Rush   bled   so   liberally, 
(par.  3476,)  were  of  this  kind,  and  come  in  to  corroborate  the 
practice. 

3506.  In  addition  to  these  means,  we  should  never  fail  to  em- 
ploy as  promptly  as  possible  after  bleeding,  the  most  powerful 
and  active  of  the  rubefacients,  as  mustard,  spirit  of  turpentine, 
Cayenne  pepper,  or  the  water  of  ammonia,  as  well  to  the  lower 
extremities,  as  to  the  region  of  the  stomach.  Indeed,  so  efficient 
have  the  latter  remedies  sometimes  been,  that  we  had  reason  to 
believe,  from  the  promptitude  of  their  action,  and  the  sudden- 
ness of  the  relief,  they  were  chiefly  instrumental  in  removing 
this  complaint. 

3507.  It  must  however  be  borne  in  mind,  that  when  the  sto- 
mach is  assailed  with  this  gouty  violence,  much  of  its  suscepti- 
bility is  destroyed;  and  to  compensate  for  this  loss,  we  must 
very  much  increase  the  quantity  of  our  remedies — three  or  four- 
fold doses  are  sometimes  required  under  such  circumstances. 

3508.  It  must  also  be  recollected,  that  the  pulse,  if  not  well 
understood  in  this  disease,  might  much  mislead  the  judgment. 
The  lancet  might  be  proscribed,  when  the  condition  of  the  pa- 
tient imperiously  demanded  its  use ;  we  must  therefore  not  per- 
mit ourselves  to  be  deceived  by  its  simulating  weakness — the 
depressed  pulse  is  almost  always  the  attendant  on  this  form  of 
gout.     Nevertheless,  it  must  be  admitted,  that  this  disease  may- 
attack  patients,  under  circumstances  in  which  it  would  be  im- 
proper to  bleed.     But  as  these  cases  cannot  be  distinctly  stated, 
we  must  leave  much  to  the  judgment  of  the  practitioner  who 
may  have  charge  of  the  case.     Much  information  however  may 
be  derived  from  taking  into  consideration  the  period  and  force 
of  the  disease;. the  habits,  age,  and  constitution  of  the  patient; 


GOUT.  783 

the  probable  power  of  tbe  system  to  react  after  bleeding;  tempe- 
rature of  the  skin,  &c. 

3509.  Should  the  bowels  be  confined,  or  even  not  freely  open, 
a  few  hours  before  the  attack,  a  stimulating  injection  should  im- 
mediately be  given ;  and  if  it  do  not  operate  speedily  it  must  be 
repeated. 

3510.  When  gout  is  translated  to  other  parts,  the  disorder  is  . 
to  be  combated  upon  general  principles,  and  by  remedies  that 
would  be  appropriate  did  it  arise  from  any  other  cause ;  recollect- 
ing always  the  very  great  utility  of  rubefacients  to  the  extremi- 
ties.    Purging  becomes  of  the  first  consequence  in  metastasis  of 
gout,  when  seated  elsewhere  than  in  the  stomach;  and  even  when 
here,  it  must  be  employed  as  soon  as  its  condition  will  permit 
the  use  of  cathartic  medicine,  without  running  the  risk  of  ne- 
glecting the  fulfilment  of  a  more  pressing  indication,  namely, 
the  relief  of  pain. 

3511.  In  colic  from  gout,  we  have  much  reliance  on  the  early 
use  of  castor  oil,  and  stimulating  enemata;  and  these  followed, 
after  proper  alvine  discharges,  by  an  enema  of  laudanum* — we 
have  already  remarked  that  an  anodyne  enema  requires  three 
times  the  quantity  that  would  be  exhibited  by  the  mouth.     A 
similar  treatment  is  required  when  the  kidneys  are  the  seat;  but 
in  addition  we  may  employ  local  bleeding,  and  the  warm  bath 
with  much  advantage.     We  have  sometimes  seen  this  affection 
removed  instantly  by  thirty  drops  of  the  spirit  of  turpentine, 
taken  as  soon  as  pain  has  been  felt  in  the  part. 

\ 
Misplaced  Gout. 

3512.  As  it  is  agreed  by  all  writers  that  the  extremities  are 
the  natural  seats  for  gout,  the  name  of  "  misplaced"  has  been 
given  to  that  species  or  variety  that  locates  itself  in  any  other 
portions  of  the  body.     Previously,  however,  to  its  fixing  itself 

*  Dr.  Chapman  warmly  recommends  the  use  of  the  volatile  tincture  of  guai- 
acum,  in  chronic,  gouty  colic;  and  we  may  add,  that  our  own  experience  is 
much  in  favour  of  its  efficacy.  We  have  also  seen  the  most  decided  advantage 
from  the  use  of  the  following  prescription,  first  recommended  to  our  notice  by 
our  friend  Dr.  Physick: — 


R.  Sp.  tereb.  rect. 
Ol.  menthse    - 
M. 


Take  Rectified  spirit  of. 

turpentine      -      6  drachms* 
Oil  of  mint  2  drachms. 

Mix. 


Of  this,  twenty  or  thirty  drops  is  to  be  taken  morning,  noon,  and  night,  in  a 
wine-glassful  of  sweetened  water.  This  is  to  be  persevered  in  for  some  time; 
and  by  which  we  have  seen  the  most  decided  relief  afforded,  in  a  number  of 
cases  of  flatulent  colic,  of  gouty  origin. 


784  GOUT. 

elsewhere  than  on  the  extremities,  it  is  known  to  wander  some- 
times to  several  parts  of  the  system,  without  tarrying  long  at 
either — when  thus  whimsical,  it  is  called  the  "  erratic  gout" 

3513.  The  misplaced,  like  the  retrocedent  gout,  is  never  uni- 
form in  its  selection  of  parts  to  fix  upon ;  it  may  be  the  head,  the 
heart,  the  stomach,  the  intestines,  or  the  kidneys.  Dr.  Chapman 
informs  us,  that  he  met  with  a  ca.se  in  the  Alms-house,  in  which 
it  repeatedly  attacked  the  penis  of  an  old  man,  occasioning  a 
painful  priapism. 

Treatment. 

3514.  As  this  species  of  gout  is  virtually  the  same  as  the  re- 
trocedent, it  must  be  treated  upon  the  same  general  principles 
that  should  govern  us  in  the  management  of  the  latter — recollect- 
ing, however,  that  it  is  an  inflammatory  transposition,  and  is  to 
be  treated   by  the  antiphlogistic   means  already  recommended. 
At  the  same  time  bearing  in  mind  the  importance  of  inviting  it 
to  its  proper  seat.     For  this  purpose,  we  know  no  application  so 
certain  as  a  pair  of  blisters  to  the  ankles — we  learnt  this  from  a 
gentleman  who  for  very  many  years  had  been  subject  to  this 
form  of  gout,  and  from  which  he  suffered  much,  until  he  could 
seduce  it  to  the  feet  by  these  means,  and  in  which  he  said  he 
had  never  been  disappointed.     It  has  not,  however,  been  so  uni- 
formly successful  in  our  hands,  though  we  think  it  more  certain 
than  any  other  that  we  have  tried. 

3515.  It  unfortunately  happens  with  patients  liable  to  this 
misplacement  of  gout,  that  they  entertain  notions  of  their  own 
upon  this  point — they  think  this  irregularity  depends  upon  de- 
bility, and  especially  of  the  stomach.     Under  this  impression 
they  take  the  most  stimulating  articles,  to  "drive  it  from  this 
organ;"  than  which  many  times,  nothing  can  be  more  unfortu- 
nate, especially  with  the  plethoric,  and  with  those  liable  to  de- 
terminations to  the  head. 

3516.  We,  however,  do  not  deny,  but  that  gout  may  attack 
those  who  have  feeble  or  exhausted  constitutions,  and  in  whom 
phlogosis  may  not  appear,  or  at  most  but  very  slightly — it  may 
therefore  become  necessary  under  such  circumstances,  to  pursue 
a  more  cordial  treatment,  and  to  recommend  a  more  generous 
regimen ;  but  these  cases  should  be  carefully  discriminated,  be- 
fore a  stimulating  plan  of  treatment  is  vigorously  adopted. 


SCROFULA.  785 


CHAPTER  XVII. 

SCROFULA. 

3517.  IN  treating  this  subject  we  are  every  way  aware,  how 
little  can  be  said  that  would  be  satisfactory,  either  as  regards  its 
pathology  or  its  treatment.  We  can  only,  therefore,  give  a  brief 
outline  of  this  interesting,  but  inscrutable  disease.     To  trace  it 
through  its  diversified  meanderings ;  to  point  out  its  modifying 
powers,  and  its  various,  and  afflicting  terminations,  would  require 
a  volume,  instead  of  the  few  pages  our  present  design  can  spare 
to  its  investigation ;  and  more  especially,  as  many  of  its  conse- 
quences become  the  province  of  the  surgeon. 

3518.  The  influence  of  this  disease  is  so  pervading,  as  to  give 
rise  in  itself  to  a  temperament,  that  is  called  the  "lymphatic 
temperament."*     Its  seat  is  principally  confined,  if  not  altoge- 

•  Dr.  Craigie,  (Elements  of  General  and  Pathological  Anatomy,  p.  239,) 
seems  to  entertain  opinions  respecting  the  lymphatics  that  are  in  opposition  to 
the  generally  received  notions  of  their  functions  in  health,  or  their  agency  in 
disease.  He  says,  "the  lymphatics  have  long  been  supposed  to  be  the  agents 
concerned  in  the  formation  of  king's  evil,  (struma,  scrofula,)  and  in  the  deve- 
lopment of  disease  when  latent.  What  are  the  proofs  of  this  opinion?  Have 
the  lymphatics  been  actually  found  disorganized  in  cases  of  strumous  disease, 
and  does  scrofula  never  take  place  without  traces  of  this  disorganization?  Do 
they  act  as  the  cause,  or  do  they  partake  in  the  effects  of  another  morbific 
agent  more  general  in  its  operation?  In  answering  these  questions  much  will 
depend  upon  the  meaning  attached  to  the  term  scrofula.  If  this  be  a  disease 
appearing  in  the  lymphatic  glands  only,  there  may  be  some  grounds  for  the 
opinion.  But  to  assemble  the  numerous  disorders  termed  strumous,  under  the 
head  of  the  lymphatics,  implies  conclusions  which  are  not  supported  by  anato- 
mical facts." 

We  regret,  that  Dr.  C.  has  not  furnished  us  With  the  causes  of  his  doubts, 
as  regards  the  location,  (at  least  in  the  general  belief,)  of  scrofulous  action; 
for  agreeably  to  our  own  impressions,  the  lymphatic  glands,  and  perhaps  the 
lymphatics  themselves,  are  in  every  instance  of  scrofulous  inflammation,  di- 
rectly involved,  whether  the  irritation  giving  rise  to  it  originate  in  them,  or 
they  only  obey  some  other  "morbific  agent  more  general  in  operation."  Dr. 
Parr  makes  "scrofula"  and  "struma"  synonymous;  and  Dr.  Cullen  confines  the 
seat  of  this  affection  to  the  conglobate  glands,  and  particularly  to  those  of  the 
neck.  Indeed  Dr.  Craigie  seems  to  answer  the  questions  he  propounds,  in  a 
manner  adverse  to  what  he  would  seem  to  insinuate,  in  another  portion  of  the 
Chapter  on  the  Lymphatic  System,  he  there  says,  "in  such  affections,  (scro- 
fulous,) these  bodies,  (lymphatic  glands,)  undoubtedly  become  the  seat  of  a 
slow  inflammatory  action,  which  is  attended  with  gradual  enlargement,  with- 
out much  pain  or  change  of  colour  in  the  integuments.  At  length,  the  gland 
is  found  to  become  softer  than  it  had  been,  and  an  opening  takes  place  in  the 
skin,  through  which  a  fluid  is  discharged,  not  homogeneous,  but  in  general 
consisting  of  a  thin  serous  water,  in  which  thicker  pieces  like  curd,  (see  par. 

99 


786  SCROFULA. 

ther,  to  the  lymphatic  glands,  or  the  lymphatics  themselves. 
The  bones,  however,  together  with  the  structures  connected 
with  the  larger  joints,  have  been  supposed  also  to  be  the  seat  of 

3520,)  are  mixed.  This  fluid,  which  is  generally  most  completely  formed  in 
suppuration  of  the  lymphatic  glands,  is  what  has  been  termed  scrofulous,  or 
strumous  matter."  p.  242. 

In  this  extract,  every  thing  is  admitted  that  would  appear  to  be  denied  just 
before;  namely,  inflammation  and  suppuration  of  the  lymphatic  glands,  and 
these  constituting  the  particular  disease  of  scrofula  or  struma.  Here  his  own 
admissions  answer  the  question,  "have  the  lymphatics  been  actually  found  dis- 
organized in  cases  of  strumous  disease,"  in  the  affirmative.  Nor  is  it  evidence, 
that  the  lymphatic  glands  are  not  liable  to  a  peculiar  inflammation,  or  an  in- 
flammation modified  by  structure,  and  of  course  peculiar  to  that  structure,  be- 
cause in  ordinary  bubo,  the  suppuration  exhibits  the  appearance  of  pus  form- 
ed in  other  tissues;  since  this  may  have  involved  only,  as  Dr.  Craigie  observes 
himself,  the  capsule  and  surrounding  cellular  substance,  and  yet  the  paren- 
chyma of  the  lymphatic  glands  may  have  an  inflammation  peculiar  to  them- 
selves; or  in  other  words,  modified  by  structure. 

We  must  regard,  therefore,  Ur.  Craigie's  views  rather  vague  upon  this  point, 
when  he  says,  (p.  244,)  "the  lymphatic  glands  as  organized  bodies  may  be 
supposed  liable  to  ordinary  inflammation."  -Yet  on  this  subject  no  very  precise 
facts  are  given.  "  The  swelling  called  bubo,  (ySot/Sav,  Hippocrates,)  appears  to 
be  in  most  cases  inflammation  of  the  capsule  and  surrounding  cellular  sub- 
stance." Now,  what  are  we  to  understand  by  the  term  "  ordinary  inflamma- 
tion?" Is  each  particular  structure  liable  to  an  inflammation,  termed  from  the 
uniformity  and  universality  of  its  phenomena,  ordinary  inflammation,  besides  a 
peculiar  one?  or  in  other  words,  is  a  tissue  liable  to  two  kinds  of  inflammation, 
the  one  "ordinary,"  and  the  other  peculiar.  Were  this  so,  it  is  evident,  that 
the  remote  cause  of  the  inflammation  must  have  the  modifying  power,  and  not 
the  tissue  or  structure,  which  has  never  yet  been  shown.  It  must  therefore  be 
evident,  that  the  "capsule"  of  a  gland  may  be  liable  to  an  inflammation  pecu- 
liar to  such  structure,  while  the  structure  which  it  invests  may  have  its  own 
laws  of  inflammation,  if  we  may  so  term  it — and  we  think  this  is  satisfactorily 
illustrated,  as  observed  above,  by  the  disease  in  question. 

Besides,  we  think  the  term  "agents  concerned  in  the  formation  of  king's 
evil,  and  in  the  development  of  the  disease  when  latent,"  does  not  convey  the 
general  impression  of  pathologists  upon  this  point — the  general  belief  is,  that 
the  lymphatics,  and  the  lymphatic  glands,  are  really  the  seats  or  the  victims  of 
scrofulous  irritation  or  action,  and  not  the  causes  or  "agents"  of  this  peculiar 
modification  of  inflammation;  for  this  supposition  would  make  them  the  active 
cause  of  the  disease  peculiar  to  themselves;  for  it  is  the  mode  of  inflammation, 
as  governed  by  the  peculiarity  of  structure  and  nature  of  the  agent  or  remote 
cause  in  the  respective  tissues  of  the  human  body,  that  gives  rise  to  variety  in 
the  phenomena  of  inflammation;  for  we  have  no  idea  of  the  essences  of  inflam- 
mation; though  we  know  from  experience,  that  various  agents  will  produce  a 
peculiar  action  in  parts  which  shall  give  rise  to  variety  in  the  phenomena  and 
result  of  inflammation.  Thus,  the  prick  ef  a  pin,  and  the  insertion  of  the 
matter  of  chancre,  gonorrhoea,  small-pox,  &c.  will  produce  their  own  peculiar 
modes  of  inflammation;  now  all  of  these  causes  except  the  first,  cannot  be 
imitated  by  any  other  agent,  or  be  made  to  change  place  with  each  other. 
From  this  it  is  rendered  more  than  probable,  that  the  nature  of  the  stimulus, 
peculiarity  of  structure,  as  well  as  the  condition  of  such  structure,  are  essen- 
tial to  the  explanation  of  the  different  phenomena  presented  in  these  several 
cases;  and  that  it  is  every  way  likely,  that  for  the  existence  or  development  of 
scrofula,  it  is  necessary  that  some  peculiar  or  specific  stimulant  or  agent,  or 
peculiarity  in  the  condition  of  the  tissue,  is  required;  for  we  do  not  believe, 


SCROFULA.  787 

this  disease;  and  giving  rise  to  affections  of  the  spine,  the  mor- 
bus  coxarius,  white  swelling,  &c.  In  cases,  in  which  the  bones 
are  involved,  it  is  said  there  is  deficiency  of  earthy  matter,  and 
an  over-quantity  of  gelatine;  but  if  this  be  admitted,  it  only 
proves  an  imperfection  in  nutrition,  and  not  an  affection  of  the 
bones  themselves,  arising  independently  of  any  condition  of  the 
lymphatic  glands  or  system.  And  of  the  other  glands,  not  lym- 
phatic, which  are  said  to  be  involved  in  this  affection,  as  the 
testicles  in  males,  the  mammae  in  females,  the  thyroid  gland, 
and  the  tarsi,  become  so,  only  perhaps  in  proportion,  as 
lymphatics  may  constitute  a  part  of  their  structure;  and  conse- 
quently, do  not  form  an  absolute  exception  to  the  rule,  that 
"scrofula  is  confined  to  the  lymphatic  glands  or  system." 

3519.  The  constitutions  most  liable  to  the  scrofulous  taint  or 
diathesis,  are  such  as  are  marked  by  certain  physical  peculiari- 
ties.    As  the  blond  complexion,  consisting  of  light  and  silky 
hair,  white  skin,  blue  eyes,  blooming  cheeks,  the  veins  easily 
traced,  the  upper  lip,  columna  nasi,  and  lower  parts  of  the  nos- 
trils, rather  swelled ;  long  and  slender  fingers;  the  chest  narrow, 
and  the  shoulders  projecting.     The  muscular  system  is  soft  and 
relaxed  ;  in  a  word,  the  whole  physical  arrangement  of  the  body 
betray  marks  of  feebleness,  or  delicacy,  though  we  would  not 
say  with  many  others,  that  this  disease  arises  from  debility.    In 
this  diathesis,  however,  the  mental  faculties  are  often  precociously 
acute,  and  vivacious. 

3520.  In  such  diatheses,  the  presence  of  almost  any  other  dis- 
ease, serves  as  an  exciting  cause,  to  the  latent  disposition;  and 
especially,  those  that  are  wont  to  run  into  a  chronic  form ;  and 
hence  the  frequency  of  complication.     Indeed,   it  sometimes 
happens,  that  we  have  no  evidence  of  the  existence  of  this  pre- 
disposition, until  it  is  thus  roused  into  action,  whatever  reason 
we  may  have  to  suspect  the  existence  of  the  temperament,  from 
the  presence  of  physical  signs.     At  other  times,  the  lymphatic 
glands  are  found  enlarged,  and  discover  themselves  in  various 
parts  of  the  body,  but  especially  in  those  of  the  neck.     These, 
however,  in  some  instances,  remain  stationary  during  life;  while 
at  other  times  they  gradually  develope  themselves,  by  a  slow  and 

that  if  any  ordinary  cause  capable  of  producing1  inflammation  were  applied  to 
a  perfectly  healthy  structure,  that  it  would  produce  any  thing1  beyond  an  in- 
flammation that  would  be  readily  subdued  by  the  common  powers  of  the  sys- 
tem— thus,  if  a  perfectly  healthy  lymphatic  gland  were  irritated  to  inflamma- 
tion, that  gland  would,  not  merely  from  structure,  take  on  or  assume  the 
inflammation  we  constantly  observe  in  a  similar  gland,  but  which  labours  under 
the  scrofulous  diathesis.  We  think  this  circumstance  is  abundantly  illustrated 
by  the  difference  of  consequences  of  the  common  bubo.  In  one  instance  it  is 
inflamed  even  to  suppuration,  yet  heals  without  extraordinary  trouble;  while 
in  the  other,  it  heals  with  great  difficulty,  or  perhaps  not  at  all. 


788  SCROFULA. 

peculiar  inflammation,  ending  most  commonly  in  ulceration.  * 
The  sores  produced  by  the  suppuration  of  scrofulous  glands,  are 
always  difficult  to  heal;  and  the  whole  progress  to  this  condition 
is  accomplished  with  much  difficulty ;  the  pus,  if  it  deserve  the 
name,  resembles  whey  with  small  flakes,  like  the  curd  of  milk, 
or  is  ichorous,  and  excoriating.  The  ulcers  have  ragged  edges, 
and  heal  with  high  cicatrices.  The  surface  of  the  sore  is  slightly 
red,  with  feeble-looking  granulations,  which  for  a  long  time  re- 
sists every  attempt  to  make  them  heal. 

3521.  There  is  perhaps  no  tissue  in  the  body,  that  may  not 
have  scrofula  developed  in  it,  because  none,  as  far  as  we  know, 
is  without  a  lymphatic  apparatus  of  some  kind  or  other.  Thus 
the  brain,  the  lungs,  the  liver,  the  spleen,  &c.  &c.  are  reported 
by  Laennec,  Louis,  Andral,  Broussais,  and  many  others,  to 
be  frequently  studded  with  tubercles,  which  appear  to  have  a 
lymphatic  origin.  No  period  of  life  perhaps  is  exempt  from 
scrofulous  development;  but  the  parts  which  take  on  this  action, 
seem  to  be  influenced  by  the  period  of  life,  or  the  advancement 

•  Mr.  Hunter  was  of  opinion,  that  the  several  changes  in  the  scrofulous 
gland,  was  not  the  result  of  inflammation.  He  says,  "many  indolent  tumours, 
slow  swellings  in  the  joints,  swellings  of  the  lymphatic  glands,  tubercles  in 
the  lungs,  and  swellings  in  many  parts  of  the  body,  are  diseased  thickenings 
without  inflammation."  In  this  opinion,  he  appears  to  have  departed  from  his 
habitual  philosophical  mode  of  investigating  the  subject  on  which  he  turned 
his  wonderfully  discriminating  mind;  for  in  all  the  instances  enumerated  as 
exceptions  to  the  formation  of  pus  without  inflammation,  it  would  be  no  diffi- 
cult matter  to  prove  previous  or  concomitant  inflammation,  or  the  abnormal 
enlargement  of  the  capillaries  belonging  to  the  several  implicated  tissues,  to 
arise  from  this  cause.  It  is  true,  that  the  lymphatic  glands  run  on  to  suppura- 
tion, without  exhibiting  some  of  the  phenomena  that  a  common  phlegmon 
presents  us  with;  yet  the  changes  they  undergo  are  nevertheless  the  result  of 
a  modified  inflammation;  since  perhaps,  their  progress  to  suppuration  can  only 
be  arrested  by  means  similar  to  those  that  have  been  found  successful  for  in- 
disputable instances  of  inflammation.  Besides,  we  have  always  found  in  glands 
thus  situated,  the  place  of  acute  suffering,  supplied  by  a  more  indistinct  dull 
sensation  when  they  were  proceeding  to  suppuration.  We  would  therefore 
conclude  that,  the  only  successful  mode  of  treating  scrofulous  inflammation, 
is  the  same  as  for  any  other  confessed  inflammation.  This  is  abundantly  proved 
in  the  treatment  of  the  hip  disease,  or  the  white  swelling  of  the  knee,  in  both 
of  which  the  progress  and  ravages  have  been  successfully  traced  to  inflamma- 
tion of  the  synovial  tissues  or  cartilages,  or  of  both.  In  these  affections,  pain, 
(more  or  less,)  heat,  and  swelling,  attended  during  life;  and  after  death,  the 
knife  revealed,  vascularity.  The  mere  absence  of  pain  as  an  initial  symptom, 
is  not  sufficient  to  prove  the  absence  of  inflammation — for  this  affection  in  its 
chronic  forms,  is  frequently  unattended  by  acute  pain,  especially  when  its  seat 
is  either  the  mucous  or  serous  tissues — nay,  they  may  even  proceed  to  the  for- 
mation of  serum  or  pus,  before  a  diseased  condition  of  the  parts  is  suspected. 

Cullen,  Good,  and  others,  consider  scrofula,  as  consisting  especially  of  debi- 
lity; yet  it  is  well  known  to  all  careful  practitioners,  that  stimulating  applica- 
tions to  the  inflamed  or  suppurating  glands,  does  mischief;  and  the  same  may 
be  said  of  highly  stimulating  articles  of  diet — hence  the  advantage  of  a  mild 
vegetable  and  milk  diet,  in  scrofulous  constitutions. 


SCROFULA.  789 

which  the  organ  makes  towards  its  final  perfection ;  for  after  this 
is  accomplished,  the  liability  seems  to  be  diminished.  Thus  the 
tendency  to  scrofulous  complications,  is  very  much  diminished 
after  the  person  has  passed  the  thirtieth  year.  But  previously 
to  this,  there  is  no  certainty,  that  phthisis  or  other  affections  con- 
nected with  a  scrofulous  diathesis,  may  not  be  developed. 

3522.  It  is  owing,  almost  certainly,  to  the  transmission  of  this 
predisposition,  that  consumption  may  with  so  much  propriety 
and  certainty,  be  looked  upon  as  hereditary.     And,  though  the 
scrofulous  taint  may  not  manifest  itself  in  the  lungs,  it  may  in 
some  other  viscera,   or  in   the  lymphatic  glands  themselves, 
strictly  so  called.    Scrofula,  like  consumption,  (or  more  properly 
perhaps,  scrofula  in  the  form  of  phthisis,)  gout,  and  epilepsy, 
may  fail  to  be  transmitted,  or  to  be  developed  in  certain  in- 
stances, where  there  may  be  hereditary  claims  to  it;  yet  the  con- 
stitutions of  such  persons  must  always  be  looked  upon  with  suspi- 
cious fear.     We  do  not,  however,  pretend  to  deny  from  what 
has  been  said,  that  this  diathesis  cannot  be  generated  in  consti- 
tutions that  are  not  influenced  by  hereditary  disposition;  for  this 
certainly  must  be  the  case,  for  the  cause  or  causes  which  was 
capable  in  the  first  instance  to  generate  scrofula,  may  combine  to 
produce  it  in  others.     It  would  seem  agreeably  to  observation, 
that  long  exposure  to  certain  causes,  may  even  in  an  untainted 
constitution,  produce  the  scrofulous  tendency;  as  climate,  air, 
mode  of  life,  and  disease  itself. 

3523.  Thus,  warm  climates  are  comparatively  free  from  scro- 
fula, while  the  people  of  countries  of  low  temperature  are  ob- 
noxious to  it;  so  are  the  inhabitants  of  cities  when  compared  with 
the  surrounding  countries;  in  Great  Britain,  witness  the  poor 
people  of  the  large,  and  crowded  manufacturing  towns;  those  of 
filthy  habits,  sedentary,  and  indolent  withal,  are  very  liable  to 
this  disease;  and  to  these  causes  we* may  add,  the  directly  debi- 
litating effects  of  scanty  food,  or  unwholesome  diet. 

3524.  In  a  practical  point  of  view,  the  knowledge  of  the  occa- 
sional causes  of  scrofula,  may  lead  to  the  prevention  of  its  deve- 
lopment, though  we  may  never  be  able  to  destroy  the  predis- 
position.    Indeed,  we  may  safely  say,  that  the  absence,  or  the 
withdrawing  of  the  exciting  causes,  may  do  more,  than  prevent 
the  immediate  development  of  the  disease;  it  may  diminish  the 
susceptibility  to  development,  which  would  be  a  great  point  gained. 

3525.  Our  attention  then  must  be  mainly  directed  against  the 
full  or  partial  development  of  this  disease ;  and  much  may  be 
done  where  every  thing  essential  to  this  end  can  be  commanded. 
When  compatible  with  the  condition  or  means  of  the  patient,  a 
change  of  climate  would  be  highly  advantageous;  and  where  this 
is  impracticable,  much  may  be  done  by  avoiding  all  unnecessary 
exposure  to  cold  and  wet — this  may  be  effected   or  guarded 


790  SCROFULA. 

against,  by  additional  clothing,  and  especially  of  the  woollen 
kind,  and  avoiding  all  unnecessary  exposure.  Flannel,  or  fleecy 
hosing  next  the  skin  is  of  much  consequence,  and  should  extend 
over  the  whole  of  the  protected  surface  of  the  body.  Females 
should  be  particularly  circumspect  in  this  particular;  they  should 
invariably  wear  worsted  stockings,  flannel  drawers,  and  chemises. 
The  city  air  should  be  changed  for  that  of  the  country;  and  par- 
ticularly that  from  salt  water,  when  it  can  be  commanded;  for 
by  this,  two  advantages  are  derived  from  the  one  source;  pure  air, 
and  sea-bathing.  In  employing,  however,  the  latter  remedy, 
much  care  is  necessary — indeed  it  should  always  be  under  the 
direction  of  the  physician,  who  will  not  permit  it  when  there  is 
cough,  or  other  visceral  disease;  or  too  little  vigour  in  the  con- 
stitution, to  produce  a  sufficient  and  healthy  reaction. 

3526.  Well-managed  exercise,  is  of  great  consequence  to  scro- 
fulous habits;  the  regular  feats  of  a  properly-governed  gymnasium, 
is  of  all  others  perhaps  the  best,  as  the  exercise  can  be  always 
accommodated,  to  the  existing  powers  of  the  patient,  and  gra- 
dually augmented  as  strength  and  agility  increase.     It  will  also 
give  a  habit  of  early  rising,  as  the  practice  of  the  gymnasium  is 
best  performed  early  in  the  morning. 

3527.  Iodine  has  of  late,  been  warmly  recommended,  by  a 
great  number  of  respectable  practitioners,  and  especially  by  the 
Germans.    Dr.  Manson  of  England  has  also  furnished  a  number 
of  interesting  cases,  in  which  this  remedy  has  been  used  with 
advantage ;  and  in  our  own  country  Dr.  Charles  Lee  Payne  of 
Lexington,  N.  C.  gives  us  a  very  interesting  case,  which  we 
will  give  from  the  "American  Journal  of  the  Medical  Sciences," 
for  August,  1830.  This  case  appears  to  us  the  more  valuable  from 
the  subject,  being  a  "  negro  man  ;"  for  agreeably  to  our  own 
observations  the  African  and  his  descendants  are  much  more  lia- 
ble to  this  disease,  than  the  whites  of  America.    "A  negro  man, 
aged  29,  thick  lips,  thin  and  delicate  skin,  about  two  years  ago 
received  some  injury  from  a  blow  on  the  face ;  a  few  months 
afterwards  the  submaxillary  glands,  and  the  glands  of  the  neck, 
began  to  swell  and  harden ;  soon  afterwards  he  was  put  under 
medical  treatment,  but  no  permanent  benefit  was  derived  from 
the  plan  pursued,  and  the  glands  of  the  neck  became  successively 
more  and  more  enlarged — suppuration  took  place,  and  the  mat- 
ter, which  was  of  a  sero-purulent  and  flaky  appearance,  was  dis- 
charged by  numerous  foraminae. 

3528.  "  In  this  situation,  with  the  neck  extremely  swollen,  the 
patient  came  under  my  care,  about  the  1st  of  January,  1829. 
Without  any  preparation,  1  immediately  commenced  the  treat- 
ment by  giving  him  twenty  drops  of  the  tincture  of  iodine  three 
times  a  day,  cautiously  and  gradually  increasing  it  to  forty-five 
drops,  and  at  the  same  time  used  the  ointment  of  the  hydriodate 


SCROFULA.  791 

of  potash  by  friction  to  the  tumours.  In  three  weeks  a  decided 
impression  was  made,  but  the  disease  appeared  more  to  remain 
stationary,  which  induced  me  to  employ  the  iodine  in  larger 
doses  than  I  had  before  heard  of  its  being  given — forty-five 
drops  three  and  four  times  a  day,  watching  however  all  the  time 
carefully  its  effects.  In  this  way  I  continued  until  he  had  taken 
about  eight  ounces  of  the  tincture,  when  I  thought  prudent  to 
wait  a  short  time,  thinking  there  might  be  some  danger  in  going 
further,  and  that  habit  might  have  some  influence  in  lessening 
the  effects  of  the  medicine.  My  patient  however  continued, 
(without  taking  any  more,)  te  improve,  and  in  about  four  months 
from  the  time  of  commencing  was  discharged  perfectly  cured. 
Not  a  vestige  of  the  disease  has  since  appeared,  notwithstanding 
he  has  been  actively  and  laboriously  engaged  at  the  gold  mines." 

3529.  "  No  other  medicines  were  used  during  the  treatment; 
for  I  determined  at  the  beginning  to  test  the  virtues  of  the  iodine 
in  this  disease,  unless  the  case  should  contraindicate  its  use,  or 
appear  imperiously  to  require  the  use  of  other  medicines." 

3530.  "  During  the  whole  courseof  treatment  the  patient  walk- 
ed about,  and  never  expressed  the  least  uneasiness  from  the  use 
of  the  medicine.     No  other  sensible  effect  was  produced  on  his 
constitution  except  that  he  became  considerably  emaciated ;  he 
however  soon  gained  his  usual  strength,  and  became  quite  fat, 
after  the  disease  had  entirely  left  him." 

3531.  The  formula  used  of  the  tincture  was  of  iodine  thirty 
grains  to  the  ounce  of  alcohol. 

3532.  Of  the  ointment,  forty-eight  grains  of  hydriodate  of 
potash  to  the  ounce  of  prepared  lard. 

3533.  A  generously  nutritious  diet,  should  be  adopted ;  all 
unnecessary  stimuli  should  be  shunned.    The  stomach  should  be 
gratefully  stimulated  by  the  vegetable  mucilages,  as  the  rice, 
sago,  tapioca,  arrow  root,  &c.  together  with  as  much  animal  food 
as  is  necessary  to  preserve  its  tone,  but  not  sufficient  to  oppress 
it.  All  crude  substances  should  be  carefully  avoided — all  unripe, 
or  ascescent  fruit,  should  be  forbidden. 

3534.  We  have  little  reliance  in  general,  upon  medicine  in 
this   disease;    though  it  is  every  way  important  to  keep    the 
bowels  well  regulated — for  this  purpose  we  believe  the  simple 
rhubarb  pill  is  the  best.  Should  the  glands  threaten  suppuration, 
it  must  be  avoided  as  long  as  possible,  by  attending  to  the  state 
of  the  system — that  is,  keeping  down  arterial  action,  by  gentle 
purging,  a  nutritious,  but  a  vegetable  diet,  and  by  the  frequent 
bathing  of  the  part  with  cold  salt  and  water.   If  suppuration  have 
taken  place,  the  diet  should  be  more  generous,  but  never  stimu- 
lating— tonics  may  be  given  in  combination  with  the  compound 
syrup  of  sarsaparilla;  and  the  sores  washed  two  or  three  times  a 
day,  with  a  decoction  of  carrots. 


PRESCRIPTIONS. 


TOAST  WATER. 

Take  a  piece  or  slice  of  stale  sweet  bread ;  toast  it  gradually 
until  quite  brown,  and  then  immerse  it  suddenly  in  cold  water — 
covering  the  vessel  for  a  short  time. 


TOAST  TEA. 

Toast  bread  as  directed  above ;  crumble  it  in  a  tea-pot,  and 
pour  boiling  water  on  it — when  cold,  strain. 


APPLE  WATER. 

Roast  two  or  three  apples,  and  while  hot,  pour  a  pint  of  boil- 
ing water  for  each  apple ;  beat  them  well  up,  and  when  cold, 
strain  for  use. 


TAPIOCA,  SAGO,  AND  ARROW  ROOT  JELLIES. 

Take  a  table-spoonful  of  either  of  these  substances ;  pour  on 
either  a  pint  of  cold  water,  and  boil  it  gently  until  it  is  a  trans- 
parent jelly — sweeten  with  loaf  sugar  to  your  taste,  and  grate  on 
it  a  little  nutmeg,  or  season  with  lemon  juice. '  The  arrow  root 
and  water  should  be  mixed  intimately  before  boiling — this  is  not 
necessary  with  either  of  the  other  substances. 


COLD  COSTARD. 

Take  the  yolk  and  white  of  an  egg,  and  one  table-spoonful  of 
the  best  brown  sugar;  beat  together  in  a  vessel,  until  the  tenacity 
of  the  white  of  the  egg  is  entirely  destroyed — add  gradually, 
(stirring  it  constantly,)  half  a  pint  of  cold  water,  and  two  tea- 
spoonfuls  of  rose  water,  and  a  little  grated  nutmeg.  A  wine- 
glassful  of  this  may  be  taken  every  two  or  three  hours. 


PRESCRIPTIONS.  793 


SIMPLE  CERATE. 

Take  olive  oil,  fresh  hog's  lard,  and  spermaceti,  six  parts, 
bees-wax,  four  parts — melt  together  slowly. 


BASILICON. 

Take  of  hog's  lard,  eight  parts ;  white  resin  or  rosin,  five  parts; 
bees-wax,  two  parts — melt  together  slowly. 


SPIRIT  OP  MINDERERUS. 

Take  of  the  carbonate  of  ammonia,  in  powder,  two  ounces. 
Add  by  small  portions,  with  frequent  stirrings,  as  much  distilled 
vinegar,  as  shall  be  sufficient  to  saturate  the  ammonia  exactly, 

N.  B.  This  should  always  be  made  fresh. 


CHALK  JULEP. 

Take  of  prepared  chalk,  one  ounce ;  white  sugar  half  an  ounce; 
gum  Arabic,  quarter  of  an  ounce ;  spirit  of  cinnamon,  two  ounces; 
water,  two  and  a  half  pounds. 

Rub  down  the  gum  with  four  ounces  of  water.  Then  rub  the 
sugar  with  the  spirit  of  cinnamon,  or  four  drops  of  the  oil  of  cin- 
namon ;  then  mix  the  whole  together. 

This  should  be  made  fresh.  A  table-spoonful  of  this  may  be 
given  frequently  to  an  adult,  during  the  day,  and  a  tea-spoonful 
or  more  to  a  child. 


RHUBARB  PILLS. 

Take  powdered  rhubarb,  one  drachm;  oil  of  caraway,  six  drops; 
soap,  six  grains;  syrup  of  rhubarb,  a  sufficient  quantity  to  make 
into  a  mass;  divide  into  fifteen  pills. 


100 


GLOSSARY, 

EXPLAINING  THE  TECHNICAL  TERMS  USED. 


A. 

•flbscess,  a  collection  of  pus  or  matter. 
Abdomen,  the  belly  or  paunch. 
Abdominal  viscera,  the  contents  of  the  abdomen. 
•flbortion,  miscarriage. 

•Antiphlogistic,  medicines  that  reduce  an  inflammatory  habit. 
Axillary ',  belonging  to  the  arm-pit. 
^normal,  unnatural  or  unhealthy  state. 
Jtponeurosis,  the  tendinous  coverings  of  the  joints. 
•SEgophonism,  is  the  trembling  or  jerking  sound  of  the  voice, 
like  the  bleating  of  a  goat. 

B. 

Bronchophonism,  the  sound  of  the  voice  in  the  large  bronchial 
tubes. 

Bronchial  respiration,  the  sound  of  the  respiration  as  it  exists 
in  the  larynx,  trachea,  and  larger  bronchial  trunks. 

Blowing  or  puffing  respiration,  is  observed  sometimes  when 
the  patient  is  breathing  quickly  and  by  fits ;  during  inspira- 
tion the  air  appears  as  if  drawn  from  the  auscultator's  ear ; 
while  in  expiration,  it  seems  as  if  blown  into  it. 

Borborygmus,  a  rumbling  noise  in  the  bowels,  occasioned  by 
wind. 

C. 

Cardia,  the  upper,  or  left  orifice  of  the  stomach. 

Catamenia,  the  monthly  discharge  of  women. 

Chyle,  a  white  fluid  produced  by  digestion. 

Colyrium,  a  wash  for  the  eyes. 

Coma,  lethargic  drowsiness. 

Congestion,  accumulation  of  blood  in  a  part. 

Crisis,  termination  of  a  disease  by  some  sign. 

Cathartics,  purging  medicines. 

Chronic,  long-continued  disease. 

Capillaries,  the  minute  hair-like  vessels  of  the  system. 

Crepitous  rattle,  resembles  the  sound  produced  by  the  crepita- 
tion of  salt  exposed  to  heat,  or  that  produced  by  blowing 
into  a  dried  bladder. 


GLOSSARY.  795 

D. 

Diaphragm,  a  muscle  which  separates  the  belly  from  the  chest. 

Dorsal,  belonging  to  the  back. 

Duodenum,  the  first  bowel  below  the  stomach. 

Dyspepsia,  depraved  digestion. 

Diaphoretics,  medicines  to  promote  perspiration. 

Diaphoresis,  perspiration. 

Diathesis,  a  disposition  or  affection  of  any  part. 

Diagnosis,  discriminating  one  disease  from  another. 

Diuretics,  medicines  that  promote  the  secretion  of  urine. 

E. 

Enema  or  Enemata,  injection,  or  injections. 
Excitability,  the  capacity  to  be  acted  upon  by  stimuli. 
Excitement,  the  action  produced  by  the  application  of  stimuli. 
Exfoliate,  the  act  of  casting  off  dead  bones  or  scales. 
Epidemic,  diseases  that  prevail  generally,  attacking  many  at  the 

same  time. 

Endemic,  diseases  affecting  a  particular  people  or  country. 
Engorgement,  accumulation  of  blood  in  a  part. 
Exacerbation,  moment  of  increase  of  a  fever. 
Exanthemata,  acute  eruptive  diseases. 
Expectorants,  medicines  to  promote  spitting. 
Erythema,  a  slight-  inflammation  of  the  skin  or  other  parts. 
Erysipelas,  St.  Anthony's  fire. 

F. 

Farinaceous,  mealy. 

Febrile,  feverish. 

Febrifuge,  that  which  has  the  power  to  remove  fever. 

G. 

Gangrene,  a  mortification,  or  nearly  the  loss  of  life  of  a  part. 

H. 
Haemorrhages,  spontaneous  bleedings  from  any  part  of  the  body. 

I. 

Idiopathic,  an  original  affection  of  a  part 
Iliac  passion,  dry  belly-ache. 

•••:.,. 

Lateritious,  brick-coloured. 
Leucorrhasa,  the  whites. 
Lumbar,  belonging  to  the  loins. 


796  GLOSSARY. 

M. 

Miasm,  sing.  Miasmata,  plur.  any  fume  or  effluvia  capable  of 

producing  disease. 
Meninges,  coverings  of  the  brain. 
Mucus,  a  peculiar  tenacious  secretion. 
Mucous,  that  which  partakes  of  mucus. 
Metallic  tinkling,  a  sound  resembling  the  striking  of  a  cup  of 

metal,  glass,  or  porcelain. 

N. 

Nausea,  sickness  at  stomach. 
Normal,  natural  or  healthy  state. 

0. 

(Esophagus,  the  gullet. 
Ophthalmia,  an  inflammation  of  the  eyes. 
Oxygen,  basis  of  vital  air. 
Oxygenation,  acquiring  oxygen. 

Orthopncea,  a  difficulty  in  breathing  in  which  the  patient  cannot 
lie  down. 

P. 

Pectoral,  belonging  to  the  breast. 

Physical,  that  which  relates  to  natural  agents — that  which  is 
opposed  to  moral. 

Physiology,  the  doctrine  which  teaches  the  use  and  actions  of 
living  parts. 

Plethora,  fulness  of  blood. 

Pus,  the  matter  found  in  abscesses,  and  other  parts,  after  in- 
flammation. 

Pustule,  an  ulceration  of  the  cuticle,  with  an  inflamed  base  con- 
taining pus. 

Paroxysm,  an  access,  fit,  or  exacerbation  of  a  disease. 

Phlegmasia,  inflammation. 

Phlegmonous,  inflammatory. 

Pre  re  nata,  as  occasion  may  require. 

Prognosis,  foretelling  the  event  of  a  disease. 

Pathology,  morbid  appearance  of  diseased  parts. 

Pathognomonic,  characteristic  symptoms  of  a  disease. 

Purulent,  consisting  of  pus. 

Post  mortem,  after  death. 

Percussion,  the  striking  of  the  chest  with  the  extremities  of  the 
fingers  so  as  to  make  it  render  its  sound. 

Pectoriloquism,  perfect,  is  the  transmission  of  the  voice  through 
the  stethoscope,  when  applied  to  the  chest. 


GLOSSARY.  797 

Pulmonary  respiration,  is  the  sound  or  slight  murmur  render- 
ed by  healthy  lungs,  on  the  application  of  the  funnel-end  of 
the  stethoscope. 

R. 

Rickets,  a  disease  of  the  bones. 

Battle,  expresses  the  sounds  besides  those  of  healthy  respira- 
tion, which  give  rise  to  the  sensation  of  air  passing  through 
a  fluid  in  the  lungs. 

S. 

Sanguiferous  system,  the  blood-vessels,  both  arteries  and  veins. 
Scirrhus,  a  tumour  affecting  glands. 
Scrotum,  the  bag  under  the  penis  containing  the  testicles. 
Secretion,  the  separation  of  various  fluids,  and  other  matters, 

by  glands  from  the  blood. 

Symptomatic,  arising  from,  or  indicative  of  some  other  affection. 
Syncope,  fainting  fit. 
Subsultus  tendinum,  a  convulsive  motion  of  the  sinews  of  the 

wrist. 
Synochus,  a  sub-acute  inflammation. 

T. 

Tenesmus,  an  ineffectual  urging  to  go  to  stool. 

Tormina,  a  griping  pain. 

Tubercle,  a  small,  hard,  superficial  tumour,  circumscribed  and 

permanent,  or  suppurating  partially. 
Type,  the  peculiar  character  assumed  by  a  disease. 

U. 

Uterus,  the  womb. 

Utero-gestation,  the  term  of  pregnancy. 

V. 

Vesicate,  to  blister. 
Vesication,  blistering. 


EXPLANATION 


OF   THE 

PLATE  OF  THE  PATTERNS  FOR  BLISTERS. 


Fig.   1.  Pattern  for  blister  to  go  between  the  shoulders. 


2. 
3. 
4. 
5. 

6. 

7. 
8. 


for  the  chest  of  a  female. 

for  the  chest  of  a  male. 

for  the  side. 

for  the  calves  of  the  legs. 

for  the  chest  of  a  child. 

for  behind  the  ear. 

for  inside  of  the  thighs — these  differ 


from  those  for  the  calves  of  the  legs,  in  being  a  little  broader. 

Fig.  1.  Fig.  2.  Fig.  3.  Fig.  4. 


Fig.  5. 


Fig.  6. 


Fig.  7. 


Fig.  8. 


IXDEX. 


Gjr"  The  first  numbers  refer  to  the  paragraph,  and  the  latter  to  the  page  at 
which  the  subject  commences. 


A. 

Anasarca 

symptoms  of  ... 

causes  of         .... 

oedema        •    -   -    -        - 
causes  of 

treatment  of        ... 
Antispasmodics  in  pertussis 

cystitis     ... 
Apoplexy 

remarks  on    - 

definition  of  ... 

premonitory  signs  of      - 
stertor  .... 

respiration  and  pulse 
a  case  of        -        -        -     -  - 
skin,  temperature  of      - 
eyes  and  teeth,  appearance  of 
causes,  predisposing 
life,  time  of  -        •  "'•.- 

causes,  exciting      -        -        - 
pathology  of          -        - 
cause,  proximate 
experiments  on  animals 
experiments  relative  to  man 
M.  Serres'  observations  on 
division  of 

first,  meningeal      ... 
second,  cerebral     - 
mode  of  attack  of  meningeal 
mode  of  attack  of  cerebral 
dissections     .... 
treatment       .... 
prophylactic 
during  paroxysm 
Arsenic  in  intermittent  fever 
Arsenical  solution  in  intermittent  fever 

pertussis,  use  of 
Ascites,  or  dropsy  of  belly 
acute,  treatment  of 
definition  of 
symptoms  of     - 
pulse,  state  of  - 
diagnosis  .... 

prognosis 

dissections        .... 
regimen         ^ 
purging  in         -        •  -  •  .. - 
diuretics  in 


Paiv   Page. 

3240 
3241 
3246 
3247 
3248 
3251 
1512 
3026 

766 

768 

770 

772 

774 

777 

782 

783 

786 

788 

790 

791 

792 

793 

802 

804 

812 

814 

826 

814 

827 

820 

839 

840 

850 

294 

295 
1530 
3211 
3223 
3211 
3212 
3216 
3217 
3219 
3222 
3225 
3226 
3228 


800 


INDEX. 


Asafcetida  in  tetanus,  use  of 

pertussis,  use  of 

Auscultation  in  pneumonia  -        -        - 

bydrothorax        ... 

B. 

Bark  in  intermittent  fever  ... 

erysipelas        -        -        - 
and  wine  in  tetanus      .... 

pertussis    - 
Bath,  warm  and  cold  in  tetanus,  use  of 

in  colic      -        -        -        -    .    - 
cystitis  .... 

nephritis        .... 
haemoptysis  ... 

Belly-ache,  dry,  see  ileus. 
Bilious  colic,  see  colic. 
Bladder,  inflammation  of,  see  cystitis. 
Bleeding  in  fever         -        -        - 

from  the  nose,  see  epistaxis. 
in  cold  stage  of  intermittent  fever 
remittent  fever        - 
continued  fever        ... 
yellow  fever    - 

measles  .... 

jugular  vein  .... 
erysipelas  .... 
phrenitis  - 

catarrh    ----- 
cynanche  tonsillaris 
pertussis 

pneumonia  .... 
pleuritis  - 

acute  phthisis 

jaundice  .... 

dysentery        -        -        - 
enteritis  • 

ileus        - 

nephritis  .... 
diabetes  .... 
hydrocephalus  ... 
rheumatism  -  -  ,  - 

gout 

Blisters  in  fever  -        - 

intermittent  fever      - 

remittent  fever  ... 

continued  fever          ... 

erysipelas 

phrenitis 

catarrh       


croup 

pneumonia 

pleuritis     - 

enuresis 

hydrocephalus 

haemoptysis 

conjunctivitis 

sclerotitis 


Par.   Pajr*. 

1017 

305 

1515 

440 

1577 

456 

3197 

689 

287 

91 

709 

218 

1012 

303 

1521 

441 

1009 

303 

2063 

610 

3026 

630 

3034 

633 

3324 

725 

229 

75 

330 

105 

341 

114 

377 

125 

523 

164 

564 

176 

1399 

414 

687 

213 

753 

232 

1292 

388 

1332 

398 

1486 

433 

1580 

457 

1687 

495 

1814 

538 

1903 

568 

1992 

588 

2035 

602 

2075 

614 

3047 

637 

3085 

650 

3186 

684 

3410 

752 

3476 

773 

258 

83 

300 

96 

349 

117 

384 

127 

698 

216 

762 

234 

1312 

394 

1414 

417 

1603 

466 

1691 

497 

3117 

660 

3195 

688 

3323 

725 

1115 

336 

1190 

354 

INDEX. 


801 


Blisters  in  corneitis 

Bowels,  inflammation  of,  see  enteritis. 

Brain,  dropsy  of,  see  hydrocephalus. 

C. 

Carditis 

Catarrh       -        -        -        -        - 
symptoms  of     - 
in  the  adult       - 
severer  forms  of 
cause  of    -        -        -        -        - 
pathology  of     - 
bleeding1  in 

children  more  liable  to      - 
signs  for  use  of  lancet 
cupping  in 
tumefaction       - 
leeches,  effect  of 
purging  in 
puking  in          - 

squills,  syrup  of        -        -.••,- 
opium,  use  of  in 
regimen    -        -        -        - 
blisters  in          - 
Chorea,  or  St.  Vitus'  Dance 
remarks  upon 
symptoms  and  progress  of 
two  species  of  - 

idiopathic          - 
predisposing  causes 
exciting  causes         - 
prognosis          - 
treatment          - 

Cold,  taking        -        -        -        - 
action  on  the  lungs  in  phthisis 
effects  of,  on  rheumatism 
Colic,  character  of 

crapulous     

causes  of  - 

diagnosis  of 
prognosis          - 
treatment  of     - 

bilious          -        -        -        -   .     - 
symptoms  of     - 
treatment  of 
cathartics  in 
enemata  in    - 
-  blood-letting 
warm  batl'  in 

Colica  pictonum,  or  painter's  colic 
symptoms  of 
diagnosis    - 
prognosis 
pathology  of       - 
treatment  of 
antiphlogistic  plan  in 
case  of 
Conical  cornea,  see  eyes. 


Par. 

1214 


1848 
1276 
1277 
1283 
1286 
1287 
1288 
1292 
1294 
1295 
1298 
1300 
1301 
1304 
1307 
1309 
1310 
1311 
1312 

953 

954 

958 

959 

960 

962 

ib. 

963 

211 

1823 

3397 

2047 

2049 

ib. 

2051 
2052 
2053 
2054 
2055 
2057 
2060 
2061 
2062 
2063 


101 


802 


INDEX. 


Consumption,  see  phthisis  pulmonalis. 

Conjunctivitis,  see  eyes. 

Contagion  of  scarlatina         ... 

erysipelas       ..... 

pertussis         -        -        -        - 

consumption  .... 

dysentery        -.-... 
Cornea,  ossification  of,  see  eyes. 
Corneitis,  see  eyes. 
Cough  in  pneumonia  ..... 

pleurisy       ...... 

Croup,  see  cynanche  trachealis.  » 

Cynanche  parotidaea,  or  mumps 

consists  of     -        -        -        - 

progress  unattended  by  fever 
translation  of         -        •  .       . 
treatment  of          ... 
tonsillaris,  or  sore  throat      ... 
symptoms  of  simple  form 
phlegmonous  inflammation  in 
symptoms  of  higher  stage 
causes  of        -        ... 
treatment  of  ... 

gargle         .... 

bleeding  in         ... 
erysipelatous  species 
trachealis,  or  croup     .... 

remarks  upon         ... 
causes  of 
attack,  mode  of 
symptoms  of          ... 
hoarseness,  peculiarity  of 
first  stage  of          ... 
signs  of          .... 

second  stage  of 

third  stage  of          ... 

symptoms  of          - 

dissections      - 

membrane,  formation  of 

Dr.  Watts'  observations  on 

treatment  of  ... 

first  stage  of 

second  stage  of 

third  stage  of 

stimulating  applications 
purging  in 

jugular  vein,  bleeding  in 
rubefacients,  use  of    - 
leeching  in 

puking       .        .        -        , 
blisters        - 
warm  bath  - 

laudanum  with  antimony     - 
obstruction,  mechanical 
polygala  seneka 
tracheotomy       - 
Cystitis,  or  inflammation  of  bladder     - 

symptoms  of 


Par.       Page. 


587 

650 

1463 

1759 

1970 


1557 
1637 


1440 
1443 
1446 
1448 
1320 
ib. 
1321 
1324 
1328 
1330 
1331 
1332 
1335 

1338 
1341 
1343 
1347 
1353 
1358 

ib. 
1363 
1364 
1365 
1372 
1374 
1376 
1380 

ib. 
1391 
1422 
1395 

ib. 
1399 
1403 
1408 
1413 
1414 
1415 
1420 
1425 
1431 
1436 

3016 


INDEX, 


803 


Cystitis,  terminations  of,  various 

resolution  of 

suppuration  in  .... 

gangrene  in 

causes  of          -        -        -        - 
treatment  of 

depletion,  general,  in 

urine,  attention  to 

catheter,  introduction  of 

warm  bath,  use  of 

antispasmodics,  use  of 

calomel  and  opium,  combined  use  of 

regimen 

chronic,  or  cystirrhcea — catarrhus  vesicae 

symptoms  of 

pathology  of 

treatment  of 

D. 

Diabetes - 

definition  of      -        -        -        -        - 
divided  into  two  species    •---»•« 

symptoms  of 

progress  of  -        -     .  - 

appearance  of  blood  in 
proximate  cause  of  - 
anatomical  characters  of  -        - 

pathology  of 

prognosis  of 

treatment  of 

blood-letting  in         .... 
state  of  pulse  in 
Dr.  Watt's  case  of    - 
Dr.  Ferriar's  case  of 
regimen  in        - 

Diarrhoea     - 

feculent 

bilious 

i      mucous     - 

chylous 

lienteric 

chronic 

causes  acting  directly        ... 

indirectly     ... 

treatment  of  feculent         ... 

bilious  -        --. 

mucous          ... 

ohylous 

lienteric         ... 
chronic  ... 

laudanum,  use  of,  in          -        -      -  - 
faeces  in  bilious          .   •     - 

mucous       .... 

-    chylous       .... 

lienteric      .... 

seat  of 

chronic,  cause  of  difficulty  in  cure  of 
Dropsy  of  head,  see  hydrocephalus. 


Par. 
3017 
3018 
3019 
3021 
3022 
3023 

ib. 
3025 

ib. 
3026 

ib. 

3027 
3028 

3030 
3032 
3033 


3063 
3064 
3065 
3068 
3070 
3072 
3080 
3083 
3084 
3085 

ib. 
3086 

ib. 

3088 
3089 

1909 
1923 
1934 
1939 
1942 
1947 
1911 
1916 
1913 
1926 
1936 
1940 
1945 
1948 
1921 
1923 
1934 
1939 
1942 
1944 
1948 


804 


INDEX. 


Dropsy  of  chest,  see  hydrothorax. 

belly,  see  ascites. 

Dysentery 

symptoms  and  character  of 
evacuations,  character  of 
diagnosis         -        -  -     - 
nosology  of    - 
pathology  of  - 
bowels,  ulceration  of,  in 
bloody  discharges  in 
causes  of         - 
contagion  of  - 
terminations  of        - 
evacuations,  examinations  of  - 
conversion  into  other  disease's 
chronic   - 

causes  of  chronic  form     - 
fever  rarely  attendant  on 
change  of  countenance  in 
effect  on  mind  of    - 
pathology  of  chronic 
complications  of      - 
prognosis  in    - 
treatment  of  chronic  form 
convalescence  from 
exercise,  use  of,  in 
epidemic         - 
hiccough  in     - 
treatment  of.   - 

bleeding      - 

purgatives   • 

cathartics    - 

leeching       - 

opiates         - 

enemata       - 

diet  and  drinks    - 

blisters        - 

E. 

Enuresis,  or  incontinence  of  urine 

definition  of      -        -        -        • 
character  of,  various      -    - 
diagnosis  - 
symptoms  of     - 
causes  of  - 

complete,  form  of     - 
prognosis 

incomplete,  form  of  - 
prognosis  of 
nocturnal,  form  of    - 
Dr.  Prout's  opinion  of 
prognosis          - 
idiopathic,  form  of  - 
prognosis  of     - 
symptomatic  form  of 
prognosis  of      - 
treatment  of  first  form 

second  form 


Page. 


1960 

ib. 

1962 
1963 

ib. 
1964 

ib. 
1967 
1970 
1971 
1974 
1975 
1976 

ib. 
1977 
1978 
1979 
1980 
1982 
1984 
2005 
2006 
2007 
1985 
1988 
1991 
1992 
1995 
1996 
1998 
1999 

ib. 
2002 
2003 


3090 
3093 
3094 
3095 
3096 
3097 
3099 
3101 
3102 
3106 
3107 
3108 
3109 
3110 
3111 
3112 
3113 
3114 
3115 


INDEX. 


805 


Enuresis,  treatment  of  third  form         -        - 

blistering  in      ------- 

Enteritis     --- 

definition  of 

fever  in 

state.of  skin  in 

acute,  causes  of 

symptoms  of 

vomiting  in 

dissections        -        -   '     -    '    - 

prognosis 

treatment  of     - 

bleeding 

regimen 

purging 

leeching        ....... 

haemorrhoids  combined  with     - 

opium,  use  of,  in 

chronic     .----... 

treatment  of 

Epilepsy -        - 

attack,  mode  of 

diagnosis 

remote  causes  of      -        -        -        -        - 

prognosis 

treatment 
Epistaxis,  see  haemorrhages. 

Eyes,  diseases  of  the 

conjunctivitis        ---.--. 
physiological  characters  of 
pathological  characters  of         .... 
commencement  of  inflammation        ... 

causes       

symptoms  of  acute 

first  stage          -  

second  stage  -        -        -        -        -        - 

third  stage 

symptoms  of  chronic 

in  irritable  constitutions 

conjunctivitis,  pustular 

treatment 

blood-letting 

scarifications  of  conjunctiva  -        - 

purgatives <- 

nauseating  doses  of  antimonial       ... 

diaphoretics 

tonics 

diet 

blisters  -        -        -      .  - 

local  application's  to  the  eye 

local  applications  divided      .... 

stimulants  used  with  advantage 

of  nitrate  of  silver,  &c.  - 

of  zir.c,  copper,  lead,  &c.       -    .     - 
treatment  of  chronic  conjunctivitis    - 

in  new-born  children 

sloughing 

treatment  of  irritable  conjunctivitis 


Par. 
3116 
3117 

2008 

2011 

2014 

2018 

2019 

2023 

2030 

2031 

2034 

2035 

2038 

2039 

2041 

2042 

2044 

2045 

ib. 

901 

904 

911 

913 

939 

941 

1051 
1054 
1055 
1056 
1057 
1062 
1080 
ib. 
1081 
1082 
1088 
1092 
1096 
1097 
1098 
1108 
1109 
1110 
1112 
1113 
1114 
1115 
1116 
1118 
1120 
1121 
1123 
1126 
1128 
1129 
1131 


806 


INDEX. 


Eyes,  diseases  of  the 

treatment  of  pustular  conjunctivitis  .... 

foreign  bodies  in  - 

sclerotitis      ......... 

anatomical  character  of  the  sclerotica        ... 
physiological  characters  of        ..... 

pathological  characters  of         -        -        -        «•    .     • 
causes  of  inflammation  of          - 
gonorrhoea  a  cause    ---••-. 
with  rheumatism       ....... 

specific  virus 

symptoms  of  inflammation        -        •        -        -       "*** ' 
diagnosis  ........ 

treatment          ........ 

blood-letting         ....... 

purgatives     ........ 

diaphoretics  -        -        -        -       *. 

corrosive  sublimate 

tonics    -        -        «        -        -        -        -        -.- 

mineral  acids          ....... 

local  applications  ...... 

poppy  heads          -        -        -        -        - 

blisters  ........ 

regimen 

comeitis 

cornea,  anatomical  structure  and  physiological  characters  of 
inflammation  of  mucous  covering  membrane 
acute        ......... 

treatment      -------- 

purgatives          -        -        -        -    ,    - 

local  stimulants          ...... 

chronic 

treatment 

blood-letting 

nitrate  of  silver 

blisters       -------- 

dividing  varicose  vessels    - 
preternatural  growths  from  chronic  inflammation 
vesicular  inflammation      -        -        - 

treatment -        - 

pustular  inflammation 

treatment      -, 

purgatives          ....... 

blisters 

vinum  opii          ...---- 
ulcerative  inflammation  ? 

treatment 

inflammation  of  proper  tissue  of  cornea         ... 
acute  inflammation    ------- 

treatment 

purgatives  and  revulsives 

mercury     -------- 

chronic     

suppurative       -        .    •  *  • 

treatment      -------- 

ulcerative 

treatment      -        -        -. 

interstitial  ulcers       ------- 


Par.   Page. 

1136 
1137 
1146 

ib. 
1138 
1139 
1152 
1157 
1160 
1162 
1164 
1172 
1174 

ib. 
1175 
1176 
1178 
1184 

ib. 
1188 

ib. 
1190 
1192 

1200 
1204 

ib. 
1206 
1207 
1209 
1213 
1214 

ib. 

ib. 

ib. 

ib. 
1216 
1217 
1218 
1219 
1222 

ib. 

ib. 

ib. 
1223 
1226 
1227 

ib. 
1229 
1230 
1231 
1234 
1237 
1238 
1239 
1244 
1245 


INDEX. 


807 


Par.       Page. 
Eyes,  diseases  of  the 

conical  cornea      ........  1247 

encysted,  treatment  of  lamellz  of  cornea       -                 -  1249 

ossification  of  cornea    .......  1250 

inflammation  of  serous  lining  membrane  of  cornea        -  1251 

treatment 1253 

Erysipelas 

remarks  upon          - ^-  643 

contagion  of •-        -        -  650 

symptoms  of-        -        -        -        -        -        -        -  653 

eratic  nature  of-- 658 

(         resemblance  to  gout,  of  -        -        -        -        -        -  660 

attacking  cellular  membrane 664 

symptoms  of  this  form          .....  665 

treatment  of  this  form  674 

causes  of 678 

diagnosis 681 

treatment  of 683 

bleeding 687 

leeching 692 

purging       - 695 

blisters 698 

mercurial  ointment,  use  of           ....  702 

bark 709 

incision  and  puncturing 712 

local  applications  in 723 

F. 

Fever  in  general 

definition  of -    rv  199 

Dr.  Cullen's  opinions  of                                                    &'^  200 

Dr.  Fordyce's  opinions  of <£*'  201 

author's  remarks  on 202 

lassitude  in 203 

order  of  symptoms  in 204 

treatment,  general  plan  of           .....  205 

artificial  heat  in --  206 

temperature  of  room    -        -        - ,      -        -    '    -        -  207 

air  of  room      •'.-  •      -        -        -        -        -        -        -  208 

floor  of  room *>  209 

quiet  of  room 210 

cold,  catching  of           -        -        -        -        -        -        -'  211 

drinks  in      -                                   212 

food  in          -        -      •'•- 215 

body  clothes  in-- 218 

medicines  in         ........  219 

cure,  general  plan  of-.-----  220 

cool  air,  and  drinks  in           -        -        -        -        -   -     -  222 

bleeding  in           ..'      -        -        -        -;      .        -._-.-  229 

sweating  in 238 

purging  in            ........  250 

blisters  in 258 

when  to  be  applied               ......  259 

part  to  be  applied  to             .....  261 

duration  of  application          -        -        -        -        -  264 

peculiarity  of  patients  265 

tonics  in 266 

continued    .    •        -        -'-     —     '» 


SOS 


INDEX 


Fever,  continued. 

remarks  on     - 
symptoms  of 
cause  of 
exacerbations  of 


crisis      -- 

urine,  appearance  of 

differs  from  remittent  fever    - 

favourable  signs  of          ..... 

unfavourable  signs  of  -        -        - 

treatment  of  ...... 

bleeding      -        .        -        -        - 

purging 

blisters        ---..-. 

synochus  form 

typhus  form  ...... 

symptoms  and  remarks  upon       ... 
treatment  of        - 

purging 

decided  inflammatory  signs  in  this  disease 
pulse  and  local  determinations  in,  certain  signs 

to  treat  by 

pulse,  state  of,  in 

debility  in  ...... 

anatomical  character  .... 

best  mode  of  treating          .... 

pain  ....... 

drinks         -  

nervous  system,  state  of     - 
remote  causes    -        - 
circulating  and  nervous  systems 
disposition  to  simulate  typhus     ... 
intermittent          ........ 

definition  of          ...'.-. 
.    causes  of      ------- 

symptoms  of 

paroxysm  divided          -        .... 

objects  to  be  attempted  for  cure  of  intermittent 
fever         ....... 

opium  during  hot  stage         .... 

to  prevent  return  of  fit 

emetics      - 

bark,  use  of 

quinine     - 

emetics  after  purging  and  bleeding 
bark  and  quinine,  when  cough  exists 
arsenic,  use  of 
arsenical  solution,  use  of 
to  prevent  relapse  of    - 
bile,  as  a  cause  of  intermittent  fever 

calomel 

snakeroot 

blisters 

diet  and  drinks 
remote  cause  and  effects       - 
means  to  guard  against  it 
to  protect  the  system  from  returns 
mercury 


Par.        Page. 

363 
367 
370 
371 
372 
373 
374 
375 
376 
377 

a>. 

380 
384 
388 
398 
399 
404 
406 
410 

412 

413 
ib. 

417 
418 
420 
422 
423 
424 
432 
441 

270 
271 
272 
273 

279 
281 
286 
ib. 
287 
288 
290 
292 
294 
295 
296 
297 
298 
299 
300 
302 
305 
309 
314 
318 


INDEX. 


809 


Par.       Page. 

Fever,  intermittent 

.      clothing •'•;..  .  ..  319 

morning  and  gvening  air            -^  320 

bark  and  its  preparations  321 

cob-web             ....  327 

Dr.  Jackson's  remarks  on  328 

bleeding  in  cold  stage  of  -                          -  330 

letter  of  Dr.  Kelly         ....      .;....  ib. 

letter  of  Mr.  Gill  fb. 

remittent :-     /=.  .••j..:».  :«. 

definition  of     -        ...        -        -        .     .   .".  331 

symptoms  of            -        -        -        -        -        v ;,  332 

grades  of                   -        -        -        -        -        -  333 

danger  of                  -  334 

dissections                 335 

treatment  of             -  336 

when  to  bleed      -        -        -        .        -        r  341 

nitro-antimonial  powders       -        -        -.-"'!•-  342 

neutral  mixture    -        -        -        .',-...  ib. 

perspiration 344 

treatment  for  the  night 345 

opium           .......  ib. 

affusions  of  cold  water          -  348 

blisters          -        -.        -        -        -'                -     .  349 

treatment  modified  by  state  of  pulse         -        -  352 

violence  of  symptoms      -  353 

effects  of  remedies  354 

peculiarities  of  constitution  355 

other  prevailing  diseases  361 

diet  and  drink          -        -        -        -        .'","„  ib. 

typhus         - 

Dr.  Bancroft's  opinions        -        -        -        -        -  450 

nature  of-        -        -        -        -        -        -,-  454 

confounded  with  other  fevers       -        -        -        -  457 

Dr.  Davidge's  opinions        ......  458 

disease  of  cold  weather       .....  459 

'     never  epidemic            -        -        -        -        -        -  462 

two  modes  of  attack    ------  467 

of  the  way  of  attack  without  an  accidental  cause  469 

with  an  accidental  cause       -  470 

of  first  degree -        -  472 

second  degree          - 473 

third  degree    - '       -        -        -        -        -        -  474 

fourth  degree           ....                 .  477 

treatment  of  first  degree     -        -        -                -  481 

second  degree  484 

third  degree    -        -  _     -                 -  489 

fourth  degree        -v«   -:*                -  494 
yellow          -        -        -        -        .'.»_">.- 

definition  of          -----                 -  498 

differs  from  high  bilious  remittent  505 

mode  of  attack -  506 

three  distinct  modes  of  attack        -        -        -K  507 

first  form,  symptoms  and  progress  508 

treatment  of -        -  520 

chilly  state 522 

bleeding             . '       -       • 523 

purging     -  525 
102 


810 


INDEX. 


Fever,  yellow 

semblance  of  weakness  and  bleeding 
pathology  and  local  depletion 
sick  stomach  and  head-ache 
treatment  of  second  and  third  forms 

G. 

Gonorrhoea          ... 
consists  of    - 
symptoms  of 
diagnosis 
pathology 
treatment  of  first  stage 

second  stage 
third  stage 
gleet     -        -        . 


Gout 


divided  into  four  species 

regular 

atonic 

retrocedent       .... 
misplaced          .... 
symptoms  of     - 
proximate  cause  of  - 

predisposing  causes  of      - 
exciting  causes  of     - 
prognosis          .... 
pathological  changes        v 
treatment  of     - 
purging         .... 
emetics          .... 
bleeding        .... 
opium  .... 

sudorifics      .... 
diuretics        .... 
general  remedies 
local  applications 
regimen  during  fit    - 
atonic,  definition  of 

treatment  of          ... 
retrocedent          .... 

treatment  of 
colic  from  gout         ... 

misplaced 

treatment  of     - 

H. 

Hemorrhages 

division  of 
phenomena  of    - 
proximate  cause  of    - 
remote  causes  of 
treatment  of 
diet  in  -        -        - 

bleeding        ... 
purging 

epistaxis,  or  bleeding  from  the  nose 
haemoptysis,  or  spitting  of  blood 
causes  of 


Par. 

527 
529 

532-33 
534 


3454 
3455 
3460 
3461 
3462 
3456 
3465 
3467 
3468 
3469 
3471 
3472 
3473 
3475 
3476 
3478 
3480 
3481 
3485 
3488 
3491 
3493 
3495 
3502 
3505 
3511 
3512 
3514 


3252 
3259 
3261 
3262 
3264 
3271 
3273 
3274 
3279 
3289 
3294 


INDEX. 


811 


Haemorrhages. 

hamoptysis,  professions  create  liability  to    - 

phenomena  of 

proximate  cause  of      -        - 
treatment  of,  during  flow  of  blood 
cathartics  -        -        - 

diuretics    -  i      -        -        - 
emetics     -  »     t.  ,     • 
blisters      -        -        -        -        - 

warm  bath 

cough  in 

diet  in 

hxmatemesis       -       -  ... 

divided  into  five  species       ... 

constitutional 

succedaneous       -        .... 

splanchnic  ..... 

critical          ...... 

proximate  cause 

diagnosis      -        -        -        ..... 

prognosis      -        -        -        -        «",  -,\ •  .& 

predisposing  and  determining  causes 
symptoms  of         ..... 

treatment  of         -        -        -        -        j 

hxmaturia 

definition  of" 

symptoms  of 

renal  hxmaturia 

hsematuria  of  ureters          -        -'  .'- 

bladder         -        -        .        . 
prognosis  in  -        -        - 

treatment  of       -        -        - 
Hooping-cough,  see  pertussis. 
Hydrocephalus  internus       -        *    '    - 
definition  of   - 

divided  into  four  species         ... 
proximate  cause  of        .... 

symptoms  of 

bowels,  state  of,  in 

false  appearance  of  amendment  in  -  ;  ,  • 

prognosis  in   -        -  .     - 

dissection       ...... 

acute  symptomatic     ..... 

chronic  idiopathic      ..... 

situation  of  fluid  in          .... 

rarely  admits  of  cure       -        -        -    .....*.*; 

chronic  symptomatic          -        -        • :  "7,  • 

treatment  of 

bleeding 

purging      ...... 

sweating     ...... 

topical  applications     -        - 
sinapisms    ...... 

blisters  in    -        -        • 

Hydrothorax 

auscultation,  necessity  of  - 

signs  and  symptoms 

percussion  in  -----   - 


Par. 

3299 

3301 

3307 

3313 

3320 

3321 

332: 

3323 

3324 

3325 

3327 

3328 

3330 

3331 

3334 

3335 

3336 

3337 

3340 

3341 

3342 

3344 

3349 

3357 

3359 

3361 

3362 

3363 

3366 

3368 

3370 


3159 
3160 
3162 
3164 
3168 
3170 
3171 
3174 
3177 
3179 
3181 
3182 
3183 
3184 
3186 
3189 
3191 
3192 
3193 
3195 

3197 
3201 
3202 


812 


INDEX. 


Hydrothorax,  causes  of 
symptomatic 
symptoms  of 

Hydrophobia 

symptoms  of 
pathology  of 
treatment  of 


Ileus,  or  dry  belly-ache       .... 
symptoms  of 

causes  of 

diagnosis 

prognosis     ...... 

treatment  of         ..... 

bleeding  -        -        -        -        - 

leeching  ...... 

purgatives         ..... 

spirit  of  turpentine  ... 

opium       ...... 

Intermittent  fever,  see  fever. 
Itch,  see  psora. 
Icterus,  or  jaundice     -\ 

definition  of 

classification  of          - 

causes  of,  various      - 

infancy  and  extreme  age  less  liable  to 

error  in  diet  a  cause  of     - 

condition  of  circulating  fluid     -        -. 

urine,  consistence  of 

absorption  of  bile  into  the  blood 

symptoms  of    - 

eyes,  appearance  of,  in 

skin,  appearance  of,  in      ... 

alvine  excretions       .... 

head  also  suffers  in 

stomach,  state  of,  in 

pulse,  state  of,  in      - 

aversion  to  exercise  in 

diagnosis  ..... 

prognosis          ..... 

dissections         ..... 

treatment  of     -        .... 

blood-letting,  general        ... 

ductus  choledochus,  spasm  of 

sup-carb.  sod|c,  use  of,  in 


K. 


Kidneys,  inflammation  of,  see  nephritis. 


L. 


Lungs,  Inflammation  of,  see  pneumonia. 

M. 

Measles,  see  rubeola. 

Mumps,  see  cynanche  parotidea. 


Ptr.   Page. 

3203 

691 

3205 

ib. 

3206 

692 

1021 

306 

1036 

312 

1043 

314 

1045 

315 

1049 

317 

2065 

611 

2067 

ib. 

2068 

612 

2070 

613 

2071 

ib. 

2074 

614 

2075 

ib. 

2076 

ib. 

2077 

615 

2082 

616 

2083 

617 

559 

1874 

ib. 

1876 

ib. 

1877 

560 

1878 

ib. 

1879 

ib. 

1881 

561 

1883 

ib. 

1884 

562 

1885 

563 

1886 

ib. 

1887 

564 

1889 

ib. 

1890 

ib. 

1891 

ib. 

1892 

565 

1893 

ib. 

1895 

ib. 

1896 

ib. 

1898 

566 

1901 

567 

1903 

568 

1904 

ib. 

1906 

569 

INDEX. 


N. 
Nettle  rash,  see  urticaria. 

Nephritis    ••' 

acute * 

causes  of          -        - 

symptoms  of     -        -        - 

prognosis  -        -        -        -        -' 

diagnosis  -        - 

treatment  of     ..... 

bleeding        ...... 

purging        >        ^       - 

enemata 

blisters          -        - 

warm  and  steam  baths  - 

regimen        •-       • 

chronic - 

symptoms  of  - 

diagnosis       ...... 

prognosis      ...... 

treatment  of          -        -        -        -        - 
enemata  of  laudanum 
vegetable  diet   - 
exercise     ...... 

Nursing,  of 

injuries  from  bad      -        -        -        -        - 
dread  of  debility  and  typhus      • 
nourishment  in  acute  diseases  - 
qualifications  of  a  nurse    -        - 
faithful  administration  of  medicine     - 
drinks  and  nourishment    - 
cleanliness  in  sick  room    - 
quiet  in  sick  room    - 
ventilation  of  sick  room    - 
temperature  of  sick  room          - 
regulating  warmth  of  patient    - 
examination  and  preservation  of  excretion 
patient,  sitting  up 
making  the  bed         - 
using  utensils  for  evacuations    - 
applying  and  dressing  of  blisters 

improvement  in  the  application     -. 

period  allowed  for  drawing   - 

where  they  excite  too  much 

size  of  -        -        •        •  'f  '  • 

dressing  after  drawing  -        -        -  •     . 
administering  injections    - 
convalescence,  management  of 
relapse,  management  of   -        -        -        - 


O. 

(Edema,  see  anasarca. 

Opium,  in  intermittent  fever,  use  of    - 

remittent  fever  ... 

pertussis      .... 

pneumonia  ... 

combined  with  mercury 

phthisis       .... 

dysentery    .... 


813 

Par. 

Page. 

633 

3034 

ib. 

3035 

634 

3036 

ib. 

3040 

635 

3043 

636 

3044 

ib. 

ib. 

ib. 

3045 

637 

3046 

ib. 

3047 

ib. 

3048 

ib. 

3049 

638 

3050 

ib. 

3051 

ib. 

3052 

ib. 

3053 

639 

3054 

640 

3056 

ib. 

ib. 

ib. 

3057 

ib. 

21 

21 

ib. 

22 

23 

30 

25 

40 

ib. 

52 

30 

56 

31 

61 

23 

64 

34 

78 

36 

85 

37 

89 

38 

93 

39 

96 

40 

102 

42 

106 

44 

103 

45 

117 

46 

122 

48 

128 

ib. 

133 

50 

142 

51 

147 

52 

155 

54 

156 

ib. 

281 

89 

345 

116 

1512 

439 

1607 

467 

1621 

477 

1825 

542 

1999 

591 

314 


INDEX. 


Opium  in  enteritis 
ileus   - 

cystitis,  with  calomel 
rheumatism 
gout  - 


P. 


Paralysis,  or  palsy 

remarks  upon 861 

loss  of  sensation       -        -        -        -        -        -        -  871 

loss  of  sensibility    -.----.  872 

prognosis        -        -        -        -        -        -        --  881 

paraplegia       ........ 

partial  palsy  887 

treatment  of 892 

Pericarditis 1832 

divided  into  two  forms 1835 

chronic -        -        -  '     -  1837 

signs  of 1839 

chronic  more  frequent  than  acute    -  1842 

causes  of 1844 

treatment  of 1845 

Peritonitis -  1849 

consists  of     -        ...        - ib. 

acute -.-  1856 

attack,  mode  of 

pathology  of 1864 

treatment  of          .......  ib. 

regimen  in             1865 

chronic         .........  1866 

attack,  mode  of 1867 

symptoms  of          .......  1868 

pulse,  peculiarity  of      -        -        -        -        .        -  1870 

treatment  of 1871 

sp.  turpentine             -        -        -        .        .        •  1872 

Pertussis,  or  hooping-cough        -        -        -        ...        .  1451 

attack,  mode  of     -                ib. 

paroxysm  of          --t 1454 

Dr.  Watt's  observations  on 1457 

symptoms  of          .......  1458 

Webster  and  Gregory's  opinions  of       -        -        -  1459 

origin  of        ........  1463 

contagion  of           - ib. 

diagnosis -  1467 

Dr.  Heberden's  opinion         .....  1468 

seasons,  effect  of           ......  1469 

prognosis      ........  1471 

anatomical  character 1474 

treatment  of 1483 

bleeding             1486 

purging 1488 

Coxe's  hive  syrup,  or  syr.  scillx  comp.       -        -  ib. 

expectoration,  state  of 1490 

diet 1491 

lungs,  congestion  of 1492 

head,  determination  to 1494 

nose,  bleeding  from 1495 

calomel,  use  of,  in                  -        -        -        -        -  1496 


Par. 

2044 
2083 
3027 
3429 
3478 


INDEX. 


815 


Pertussis,  or  hooping-cough. 
Desruelles'  opinions 
definite  duration  of 
musk,  artificial,  tincture  of 
narcotics 
antispasmodics 
asafcetida       ... 
bark      .... 


quinine          -        -        - 

cantharides  with  bark  -        - 

garlic 

case      ........ 

arsenical  solution 

air,  change  of,  in  ..... 

Phrenitis 

definition  of.        -        .        -        -  •      - 
remarks  upon          - 
premonitory  signs  of       -        -  *   '  -. 
idiopathic  form  of  ."".... 

progress  of     ------- 

diagnosis          ....... 

prognosis         --.....'"*• 

treatment        ....... 

bleeding  - - 

cupping        ....... 

ice       -        -        -        .        .        .        ... 

leeching,  where  upon          .... 

Surging        -        ...... 
listers         -        -        - 
rubefacients          ...... 

Phthisis  pulmonalis,  or  consumption    - 

generally  incurable          ... 
Laennec's  observations  on 
a  case  of,  cured       - 
condition  of  lungs,  constituting 
causes  of          -        -        -        - 

development  of 

tubercles,  miliary    .... 

granular          - 
infiltration,  gray  tuberculous  - 

jelly-like        - 
progress  of      -        -        - 
tubercles,  encysted         ... 
effects  of         -        -        - 
tubercles,  when  first  appearing 
other  parts  of  body  liable  to  tubercles 
causes  of  tubercles  ... 

acute  peripneumonia 
chronic  pneumonia    - 
catarrh       .... 

pleuritis    .... 

depressing  passions    - 
a  case  of          ... 
contagion  of    -        - 
hereditary  predisposition  to     - 
tubercles,  physical  signs  of 

signs  of  softening  of 
signs  of  discharge  of 


Par. 

1499 
1505 
1507 
1512 
tft. 
1515 
1521 
1522 
1523 
1527 
1528 
1530 
1534 

731 
732 
738 
739 
743 
744 
749 
752 
753 
755 
757 
758 
761 
762 
763 

1701 
1706 
1710 
1718 
1723 
1724 
1725 
1726 
1727 
1728 
1729 
1732 
1733 
1737 
1740 
1747 
1748 
1750 
1751 
1753 
1756 
1758 
1759 
1763 
1770 
1774 
1775 


816 


INDEX. 


Par.       Page. 
Phthisis  pulmonalis,  or  consumption. 

tubercles,  symptoms  and  progress  of        -  1776 

regular  manifest      -  1778 

spitting  of  blood  in  1779 

hectic  fever  in          .....  1781 

hectic  pulse  in 1783 

rarely  below  120  beats    -        -  ib. 

diarrhoea  in -  1785 

catamenia,  disappearance  of,  in        -        -  1786 

emaciation  from 1791 

expectoration  in      -----  1795 

changes  of  -        -        -        -  1797 

irregular  manifest    -----  1804 

latent      -        -        -      ^-        -        -        -  1805 

acute 1806 

chronic 1808 

treatment  of 1809 

prevention  of  secondary  eruption  of  tuber- 
cles        1812 

softening  and  evacuation  of  tubercles  1813 

blood-letting  in 1814 

iodine,  use  of,  in  1817 

change  of  situation       ....  1819 

Dr.  Clarke's  letter  to  author  1820 

cold,  action  of,  on  lungs        ...  1823 

experiments  of  M.  Flourens           -        -  ib. 

treatment  regulated  by  symptoms        -  1824 

opium  in      ------  1825 

demulcent  drinks          ....  1827 

sweet  nitre  for  fever  in         -        -        -  1831 

elixir  vitriol  for  sweats  in     -  ib. 

Pneumonia 

remarks  upon        .......  1542 

consists  of     --------  ib. 

causes  of        --------  1545 

symptoms  of         .......  1550 

position,  effect  on  pain  1552 

pain,  seat  of 1553 

character  of 1554 

absence  of,  cause  of  error  in  treatment  1555 

right  lung  oftener  affected    -----  1556 

cough  in 1557 

spitting  relief  to  1558 

prognosis               -        - 1559 

pulse,  sign  of  stage  of  disease        -        -  1560 

skin,  state  of,  in 1565 

urine,  appearance  of,  in         -        -        -        -        -  1566 

bowels,  state  of,  in                                            *  1567 

thirst  in 1568 

terminates  favourably  by  resolution       ...  1569 

unfavourable  signs 1570 

anatomical  characters    ......  1572 

first  degree  (obstruction) 1573 

second  degree  (hepatization) 1574 

third  degree  (purulent  infiltration)         ...  1575 

whole  of  both  lungs  not  inflamed  1576 

auscultation  in 1577 

treatment  of 1578 


INDEX, 


Pneumonia,  treatment  of 

blood-letting 

quantity  regulated  by  pulse 
pulse,  variable      .... 
topical  bleeding    .... 
debility,  fear  of    - 
Laennec,  remarks  on    - 
expectoration,  stoppage  of    - 
evacuants,  general 

blisters 

alteratives 

tonics   -.---- 

opium 

tartrite  of  antimony,  large  doses  of 
Kermes'  mineral  -        -        - 
a  case  ...        .••::- ,4,- 

mercury  with  opium     -        -  -    .  £' 

Pleurisy,  see  pleuritis. 

Pleuritis - 

consists  of         - 

Cullen's  definition  of        ... 


fever,  constant  attendant  on  -        -        - 

breathing  in---.... 
pain  acute  and  local 

cough  in-- 

sputa  in     - -        - 

simple  acute     > 

extravasation  attendant  on  and  commencing  with 
effusion,  coincident  with  inflammation 
physical  signs  of        -        -        - 

prognosis *. 

diarrhoea        -        -        -        -        -     '   . 

laborious  breathing        ..... 

urine,  appearance  of     - 

termination  various        ..... 

acute  hxmorrhagic  ...... 

definition  of  -        -        -        -        -        -     ,  W  , 

symptoms  of         -        - 
chronic     ........ 

anatomical  characters 

signs  and  symptoms  of 

treatment  of     >. ..       ..... 

leeching    ....... 

cupping     -        . 

bleeding 

nitro-antimonial  powders    .... 

blisters ,  - 

tartar  emetic 

drink       "  -        .   +   ..%.      .  .-,,£, 

diet •  •"  -  -      - 

sitting  up,  effects  of 

Psora,  or  itch • . 

remarks  upon -  . 

symptoms  of    $&.-.-•      -'      •-      .-      --    •  -        • 
treatment  of 


103 


817 

Par- 

Page. 

1580 

457 

1581 

458 

1582 

il>. 

1583 

ib. 

1589 

460 

1592 

461 

1594 

462 

1599 

464 

1603 

466 

1604 

ib. 

1605 

ib. 

1607 

467 

1608 

ib. 

1610 

468 

1613 

472 

1621 

477 

ib. 

1624 

ib. 

1625 

ib. 

1630 

479 

1631 

tb. 

1633 

480 

1635 

481 

1637 

ib. 

id. 

ib. 

1643 

483 

1645 

484 

1650 

485 

1656 

487 

1660 

488 

1662 

ib. 

1664 

489 

1665 

ib. 

1667 

ib. 

1672 

490 

1673 

491 

1675 

492 

1676 

ib. 

1678 

ib. 

1681 

493 

1684 

494 

1685 

ib. 

ib. 

ib. 

1687 

495 

1690 

497 

1691 

ib. 

1692 

ib. 

1693 

ib. 

1694 

ib. 

1698 

498 

223 

724 

ib. 

725 

224 

728 

ib, 

818 


INDEX. 


R. 


Rheumatism 

symptoms  of 
fever  in 

heat  of  skin  in   - 
swellings  in 
redness  of  part  affected 
metastasis,  liability  to         - 
delirium  rarely  attendant  on 
respiration  never  directly  affected 
predisposing  causes  of 
exciting  causes  of      - 
effects  of  cold  on        - 
proximate  cause  of    - 
diagnosis  -.--., 
prognosis  and  metastasis    - 
treatment  of  acute     - 
bleeding         - 
local  .... 

purging  .... 

diuretics         .... 

sudorifics         .... 

opium    ----., 

local  applications    -  • 
chronic          ...... 

definition  of       -        - 
treatment  of      -        -        -        - 

general  bleeding    - 
cupping  and  leeching     - 
local  applications    ... 
Rubeola,  or  measles    -        -        -        -        - 

remarks  upon  .... 

symptoms  and  appearance  of    - 
confounded  with  scarlatina 
prognosis  ..... 

attended  by  inflammatory  symptoms 
of  bleeding  in  .... 

calomel,  use  of,  in     - 

typhoid  character  of  measles    - 

emetics     ------ 

consequences  of  measles 

S. 
Scarlatina,  or  scarlet  fever 

remarks  on 

divided  into  three  forms 

simplex 

anginosa       ..... 
maligna        - 

symptoms,  mode  of  attack  and  progress 
contagion  of   - 

prognosis 

treatment  of  simple  form 

anginosa     ... 
maligna  -        • 

consequences          - 
belladonna,  use  of,  in 
Sclerotitis,  see  eyes. 


Par. 

3377 
3380 
3382 
3383 
3384 
3385 
3386 
3388 
3393 
3396 
3397 
3S98 
3399 
3400 
3405 
3410 
3416 
3423 
3427 
3428 
3429 
3433 
3441 
ib. 
3446 
3447 
3448 
3449 

541 

545 
550 
552 
558 
564 
568 
570 
571 
574 


578 

ib. 

579 

ib. 

ib. 

581 

587 

588 

589 

590 

594 

595 

597 


Page. 


INDEX. 


819 


Scrofula 

lymphatic  temperament    - 
constitutions  most  liable  to 
other  diseases  act  as  exciting  causes 
all  tissues  subject  to 
effect  of  climate  on 
exercise,  effect  of,  on 
iodine,  use  of,  in 
diet  in 
Small-pox  -...-.- 

history  of 

symptoms  of 

distinct 

pathology  of 
treatment  of  . 

confluent 

prognosis         - 
treatment  of    - 

modified  variola  vaccina,  or  cow-pox    - 
vaccination 


Tetanus,  or  locked-jaw 
description  of 
rarely  attended  by  fever 
mental  functions 
causes  of 
exciting 

punctured  wounds 
pathology  of     - 
diagnosis  -        *    ' 

prognosis 
treatment 


mercury 

warm  and  cold  bath 

bark  and  wine        - 

purging         - 

spirit  of  turpentine 

caustics          - 

musk    -        -        -        -        - 

asafoetida 

Tracheotomy,  see  cynanche  trachealis. 
Typhus  fever,  see  fevers. 

U. 

Urticaria,  or  nettle  rash       ... 
symptoms  and  progress 
treatment  of    -        - 

V. 

Vaccination,  s«e  small-pox. 
Variola-vaccina,  see  small-pox. 
Vomiting  of  blood,  see  hsemrxtemesis,' 


Yellow  fever,  see  fevers. 


Y. 


Par.   Paee. 

3517 

785 

3518 

ib. 

3519 

787 

3520 

ib. 

3521 

788 

3523 

789 

3526 

790 

3527 

ib. 

3533 

791 

600 

189 

601 

ib. 

603 

190 

604 

191 

608 

192 

610 

193 

611 

ib. 

613 

194 

614 

ib. 

615 

195 

616 

ib. 

972 

287 

973 

288 

979 

289 

980 

290 

981 

ib. 

983 

292 

986 

293 

988 

294 

993 

298 

994 

ib. 

998 

300 

1006 

302 

1009 

303 

1012 

ib. 

1013 

ib. 

1014 

304 

1015 

305 

1016 

ib. 

1017 

ib. 

197 

622 

-ib.  . 

625 

199 

THE  END. 


6S/     /        '  < 


A     000  499  499     2 

UC  IRVINE  LIBRARIES 


3   1970  01996  0829 


WB100 
D5l6p 

1833 
Dewees,  William  P 

A  practice  of  physic... 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


